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Mineur L, Vazquez L, Belkacemi M, Toullec C, Bentaleb N, Boustany R, Plat F. Capecitabine/Mitomycin versus 5-Fluorouracil/Mitomycin in Combination with Simultaneous Integrated Boost Intensity-Modulated Radiation Therapy for Anal Cancer. Curr Oncol 2023; 30:8563-8574. [PMID: 37754536 PMCID: PMC10528380 DOI: 10.3390/curroncol30090621] [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: 07/31/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
Since EXTRA, a non-randomized phase II trial with 31 patients, explored the use of capecitabine, mitomycin and radiation therapy (RT) in the treatment of localized squamous cell carcinoma of the anal canal (SCCAC), this treatment has been considered as an acceptable alternative to infusional 5-FU. However, the differences in efficacy between capecitabine and 5-FU in chemoradiation therapy (CRT) with simultaneous integrated boost (SIB) radiation therapy (SIB-IMRT) for local SCCAC are not well documented. Patients included in this prospective monocentric cohort study were treated with SIB-RapidArc (a unique RT method treatment for all patients: identical technique, volume and constraints for at-risk organs), mitomycin C and 5-FU each day of RT for 7 weeks (group 1) or capecitabine each day of RT (group 2). Patients treated between July 2009 and August 2017 (group 1) and between November 2012 and April 2018 (group 2) for local SCCAC T2-4 classified as N, M0 or T, N1-3, M0 were included. Primary endpoints were progression-free survival (PFS) and acute toxicities. Results: One hundred forty-seven patients were included, 91 in group 1 and 56 in group 2. The two groups were statistically comparable in terms of sex, Eastern Cooperative Oncology Group Performance Status (ECOG PS) and TNM. With a median duration of follow-up of 53.5 months, the PFS rate at 3 years was 80% for group 1 and 75% for group 2 (p = 0.32). The 3-year colostomy-free survival rate was 92% for group 1 and 85% for group 2 (p = 0.11). The rate of patients with at least one grade 3 or higher acute toxicity was 35.5% in group 1 and 21.4% in group 2 (p = 0.10), with a trend of fewer acute toxicities with capecitabine. Conclusion: Capecitabine/mitomycin in combination with SIB RapidArc radiation therapy for anal cancer seems as effective as 5-FU-based chemotherapy and is well tolerated with minimal toxicity.
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Affiliation(s)
- Laurent Mineur
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Léa Vazquez
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Mohamed Belkacemi
- Statistics Department, PRECIS, Nouvelles Technologies, Languedoc Mutualité, 34000 Montpellier, France
| | - Clémence Toullec
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Newfel Bentaleb
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Rania Boustany
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Frederi Plat
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
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Patel C, Elmasry A, Giridharan S. Concurrent Chemo-radiotherapy in Anal Squamous Cell Carcinoma: A Retrospective Review of a Tertiary Centre Experience. J Gastrointest Cancer 2023; 54:867-872. [PMID: 36269537 DOI: 10.1007/s12029-022-00866-4] [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] [Accepted: 09/19/2022] [Indexed: 10/24/2022]
Abstract
PURPOSE Anal cancer is a rare form of gastrointestinal malignancy, and treatment is often confined to specialist centres. It has a high cure rate with non-surgical approach resulting in organ preservation. The current accepted schedule is chemo-radiotherapy (CRT) with 5-fluorouracil and mitomycin with radiotherapy doses between 50.4 and 53.2 Gray in 28 fractions. METHODS This study included patients who had histological confirmation of squamous cell carcinoma and had completed the full CRT course for anal cancer between 2008 and 2018 in our centre. Data was collected retrospectively assessing demographics, staging, surgery, relapse, latest follow-up, date of death, CRT regimen and TNM stage. Outcome data and stoma reversal rate were analysed. RESULTS Overall, 87 patients were included in the study. At diagnosis 94.3% of patients had T2-T4 disease, and 44.8% had involvement of positive loco-regional lymph nodes. Overall survival (OS) probability at 1, 3 and 5 years were 98.8%, 87.4% and 83.7%, respectively. Results also revealed a statistically significant effect of time from diagnosis to the start of radiotherapy on OS (p = 0.039). Sixty-nine (79.3%) patients achieved complete remission at last follow-up. Twenty-one patients (24%) underwent surgery for a de-functioning stoma, and only five of these patients subsequently received stoma reversal surgery. CONCLUSIONS Our data reflects the efficacy of CRT as the primary modality of treatment in the management of anal squamous cell carcinoma with effective organ preservation and disease control. Early stoma reversal may also enhance quality of life.
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Affiliation(s)
- Chantal Patel
- Oncology Department, University Hospitals of North Midlands, Newcastle Rd, Stoke-on-Trent, ST4 6QG, UK.
- Cambridge University Hospitals, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Abdelfattah Elmasry
- Oncology Department, University Hospitals of North Midlands, Newcastle Rd, Stoke-on-Trent, ST4 6QG, UK
- University Hospitals of Leicester, Infirmary Square, Leicester, LE1 5WW, UK
| | - Selvaraj Giridharan
- Oncology Department, University Hospitals of North Midlands, Newcastle Rd, Stoke-on-Trent, ST4 6QG, UK
- Keele University, Keele, Newcastle, ST5 5BG, UK
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3
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Gerardi MA, Zerella MA, Bergamaschi L, Ferrari A, Arculeo S, Bagnardi V, Frassoni S, Petz W, Fodor C, Emiro F, Cattani F, Leonardi MC, Zampino MG, Jereczek-Fossa BA. Intensity-modulated radiotherapy and cisplatin-based chemotherapy for anal cancer: long-term outcomes at a single institution. Int J Colorectal Dis 2023; 38:123. [PMID: 37162567 DOI: 10.1007/s00384-023-04400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE To evaluate oncological outcomes and late toxicities in a retrospective series of patients with locally-extended anal squamous cell carcinoma (ASCC), treated with curative Intensity Modulated Radiotherapy (IMRT) and chemotherapy. METHODS ASCC patients who underwent chemo-radiotherapy with IMRT from 2010 to 2020 were included. Oncological outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS), colostomy-free survival (CFS) and event-free survival (EFS). Late toxicity was detected according to CTCAE v.5.0 and RTOG late radiation morbidity scoring system. RESULTS Ninety-five patients were included. Most patients (83%) received chemotherapy with oral Fluoropyrimidine plus Cisplatin. The median follow-up was 5.5 years. The OS was 85.2%, 82.1% and 79.3% at 3, 5 and 8 years, respectively. The DFS was 73.1%, 70%, and 65.3% at 3, 5 and 8 years, respectively; 3, 5 and 8 years CFS was 86.2%, 84.3% and 84.3%, respectively. The EFS was 71%, 67.9% and 63.1%, at 3, 5 and 8 years, respectively. On univariable analysis, a statistically significant lower OS was found for patients with T3-T4 stage (HR = 4.58, p = 0.005) and overall treatment time (OTT) ≥ 47 days (HR = 3.37, p = 0.038). A statistically significant lower DFS was reported for patients with T3-T4 stage (HR = 2.72, p = 0.008) and Serum Squamous Cell Carcinoma Antigen (SCC) value post-RT > 1.5 (HR = 2.90, p = 0.038.). Ten severe late toxicity (≥ G3) events were reported in 8 patients (8.6%). CONCLUSIONS Our data confirm IMRT concomitant with a Cisplatin-based chemotherapy as an effective treatment of ASCC, ensuring acceptable long-term toxicities and good oncological outcomes.
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Affiliation(s)
| | - Maria Alessia Zerella
- Division of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Luca Bergamaschi
- Division of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy.
| | - Annamaria Ferrari
- Division of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Simona Arculeo
- Division of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Wanda Petz
- Department of Gastrointestinal Surgery, European Institute of Oncology, 20141, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Francesca Emiro
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Maria Giulia Zampino
- Unit of Gastrointestinal and Neuroendocrine Tumors, Division of Medical Oncology, European Institute of Oncology, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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4
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Dorth JA, Anker CJ. Patient-Reported Outcome Measures in Anal Carcinoma: Essential, But Are We Magnifying Patient Voice With the Best Megaphone? Int J Radiat Oncol Biol Phys 2023; 115:1178-1180. [PMID: 36922082 DOI: 10.1016/j.ijrobp.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 03/18/2023]
Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont; Larner College of Medicine, University of Vermont, Burlington, Vermont.
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5
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Brown E, Le Cornu E, Bui T, Bernard A, Mai T, Harvey J. Acute toxicity and patient-reported outcomes in anal canal cancer: results of a pilot study. J Med Radiat Sci 2022; 69:484-491. [PMID: 35751555 DOI: 10.1002/jmrs.604] [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: 02/08/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Anal canal cancer (ACC) is uncommon. The gold standard of care is chemoradiotherapy treatment. However, this treatment is associated with considerable acute and late side effects. The aim of this pilot study was to evaluate acute toxicity and patient-reported outcomes (PRO) in these patients from planning to 3 months after treatment. METHODS Sixteen patients were recruited to this prospective observational study from March 2015 to December 2017. All patients received volumetric modulated arc therapy (VMAT) in 30#. Toxicity data were graded by a Radiation Oncologist using the Common Terminology Criteria for Adverse Effects (CTCAE) version 4 at planning, weekly during treatment, 6-week and 3-month post-treatment. PRO data were collected using the EORTC QLQ C30 and CR29 questionnaires completed by patients at planning, mid and end treatment and 3-month post-treatment. RESULTS The majority of toxicity and PRO items peaked in severity at the end of treatment (week 6). Skin was the only item where >50% of patients had ≥ grade 2 toxicity at any point with 75% having ≥ grade 2 at week 6. Patient-reported embarrassment significantly increased over time (P < 0.001). No meaningful relationships were found between PRO and CTCAE results. CONCLUSION After reaching their maximum severity at the end of treatment, the majority of toxicity and PRO items approached baseline levels by 3-month post-treatment. The results of this study suggest that PROs are an important complementary tool to CTCAE and provide greater understanding of patients' perception of treatment side effects.
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Affiliation(s)
- Elizabeth Brown
- Radiation Oncology Princess Alexandra Hospital - Ipswich Road, Brisbane, Queensland, Australia
| | - Emma Le Cornu
- Radiation Oncology Princess Alexandra Hospital - Ipswich Road, Brisbane, Queensland, Australia
| | - Thanh Bui
- Radiation Oncology Princess Alexandra Hospital - Ipswich Road, Brisbane, Queensland, Australia
| | - Anne Bernard
- QCIF Bioinformatics, Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia
| | - Tao Mai
- Radiation Oncology Princess Alexandra Hospital - Ipswich Road, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jennifer Harvey
- Radiation Oncology Princess Alexandra Hospital - Ipswich Road, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Lester SC, McGrath LA, Guenzel RM, Quinn JC, Schultz CJ, Bradley TB, Kazemba BD, Ito S, Hallemeier CL. Vaginal Sparing Radiotherapy Using IMPT and Daily Dilator Placement for Women with Anal Cancer. Int J Part Ther 2022; 9:83-89. [PMID: 35774492 PMCID: PMC9238131 DOI: 10.14338/ijpt-21-00025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 03/04/2022] [Indexed: 11/21/2022] Open
Abstract
Sexual dysfunction is a common toxicity and detrimental for the quality of life of women treated with chemoradiotherapy for anal cancer. Sexual dysfunction occurs because the vagina is closely approximated to the anal canal and typically receives substantial doses of radiation. Strategies for mitigation have largely been focused on posttreatment therapy and symptom management. The use of daily vaginal dilator placement during radiotherapy to mitigate dose to the vagina has been previously explored with modest gains, while proton therapy is under active investigation for the treatment of anal cancer. Use of proton therapy for anal cancer reduces dose to some organs at risk but may inadvertently increase vaginal toxicity if the proton beam terminates in the vaginal tissue. Herein, we present the case histories of 2 women treated for squamous cell carcinoma of the anal canal with the novel combination of intensity-modulated proton therapy and daily vaginal dilator placement to maximally reduce dose to the vagina and protect it from areas of increased energy deposition at the end of the proton range.
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Affiliation(s)
| | | | | | - Jenae C. Quinn
- Department of Radiation Oncology Mayo Clinic, Rochester, MN
| | | | | | | | - Shima Ito
- Department of Radiation Oncology Mayo Clinic, Rochester, MN
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7
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Holliday EB, Morris VK, Johnson B, Eng C, Ludmir EB, Das P, Minsky BD, Taniguchi C, Smith GL, Koay EJ, Koong AC, Delclos ME, Skibber JM, Rodriguez-Bigas MA, You YN, Bednarski BK, Tillman MM, Chang GJ, Jennings K, Messick CA. Definitive Intensity-Modulated Chemoradiation for Anal Squamous Cell Carcinoma: Outcomes and Toxicity of 428 Patients Treated at a Single Institution. Oncologist 2022; 27:40-47. [PMID: 35305097 PMCID: PMC8842324 DOI: 10.1093/oncolo/oyab006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Although intensity-modulated radiation therapy (IMRT) is considered the standard of care for the treatment of squamous cell carcinoma of the anus (SCCA), few large series have reported oncologic outcomes and toxicities. In this retrospective report, we aim to describe outcomes and toxicities after IMRT-based chemoradiation (CRT) for the treatment of SCCA, evaluate the impact of dose escalation (>54 Gy), and compare concurrent fluoropyrimidine in combination with either mitomycin or with cisplatin as chemosensitizers.
Methods
Patients treated at The University of Texas MD Anderson Cancer Center between January 1, 2003 and December 31, 2018 with IMRT-based CRT were included. Median time to locoregional recurrence, time to colostomy, and overall survival were estimated using the Kaplan–Meier method.
Results
A total of 428 patients were included; median follow-up was 4.4 years. Three hundred and thirty-four patients (78.0%) were treated with concurrent cisplatin and fluoropyrimidine, and 160 (37.4%) with >54 Gy. Two- and 5-year freedom from locoregional failure, freedom from colostomy failure, and overall survival were 86.5% and 81.2%, respectively, 90.0% and 88.3%, respectively, and 93.6% and 85.8%, respectively. Neither dose escalation nor mitomycin-based concurrent chemotherapy resulted in improved outcomes. Mitomycin-based concurrent chemotherapy was associated with in approximately 2.5 times increased grade 3 or greater acute toxicity. Radiation dose >54 Gy was associated with approximately 2.6 times increased Grade 3 or greater chronic toxicity.
Conclusions
Our results suggest IMRT-based CRT with concurrent fluoropyrimidine and cisplatin is a safe and feasible option for patient with SCCA and may cause less acute toxicity. The role for radiation dose escalation is unclear and requires further study.
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Affiliation(s)
- Emma B Holliday
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Van K Morris
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benny Johnson
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen Taniguchi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marc E Delclos
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John M Skibber
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Y Nancy You
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mathew M Tillman
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J Chang
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Craig A Messick
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Peiffert D, Huguet F, Vendrely V, Moureau-Zabotto L, Rivin Del Campo E, Créhange G, Dietmann AS, Moignier A. Radiotherapy of anal canal cancer. Cancer Radiother 2021; 26:279-285. [PMID: 34955416 DOI: 10.1016/j.canrad.2021.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We present the update of the recommendations of the French society for radiation oncology on external radiotherapy and brachytherapy of anal canal carcinoma. The following guidelines are presented: indications, treatment procedure, as well as dose and dose-constraints objectives, immediate postoperative management, post-treatment evaluation, and long-term follow-up.
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Affiliation(s)
- D Peiffert
- Département de radiothérapie, Institut de cancérologie de Lorraine Alexis-Vautrin, avenue de Bourgogne, 54511 Vandœuvre-lès-Nancy, France.
| | - F Huguet
- Service de radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - V Vendrely
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33600 Pessac, France; Inserm U1035, université de Bordeaux, 33000 Bordeaux, France
| | - L Moureau-Zabotto
- Service de radiothérapie, institut Paoli-Calmettes, 13000 Marseille, France
| | - E Rivin Del Campo
- Service de radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - G Créhange
- Département d'oncologie radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - A-S Dietmann
- Département de radiothérapie, Institut de cancérologie de Lorraine Alexis-Vautrin, avenue de Bourgogne, 54511 Vandœuvre-lès-Nancy, France
| | - A Moignier
- Service de physique médicale, Institut de cancérologie de l'Ouest centre René-Gauducheau, 44805 Saint-Herblain, France
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9
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De B, Ludmir EB, Messick CA, Cagley MC, Morris VK, Das P, Minsky BD, Taniguchi CM, Smith GL, Koay EJ, Koong AC, Mohan R, Holliday EB. Prognostic impact of lymphopenia and neutrophil-lymphocyte ratio for patients with anal squamous cell carcinoma. J Gastrointest Oncol 2021; 12:2412-2422. [PMID: 34790402 DOI: 10.21037/jgo-21-323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/23/2021] [Indexed: 12/31/2022] Open
Abstract
Background Outcomes after definitive chemoradiation for squamous cell carcinoma are generally favorable. However, biomarkers to further yield prognostic information are desired. Treatment-related lymphopenia as well as an elevated baseline neutrophil-lymphocyte ratio have been associated with worse survival in several cancer types. We evaluated absolute lymphocyte count and neutrophil-lymphocyte ratio at baseline and at treatment-related nadir in patients with anal cancer for associations with oncologic endpoints. Methods We conducted a retrospective analysis of 428 consecutive patients with non-metastatic anal cancer treated with definitive, intensity-modulated radiation therapy-based chemoradiation. We analyzed absolute neutrophil and lymphocyte counts at several timepoints: pretreatment, weekly during treatment, and in the six weeks following treatment completion. Neutrophil-lymphocyte ratio was calculated at baseline and treatment-related nadir. We estimated oncologic endpoints using life tables and compared them using the log-rank test. We conducted univariate and multivariable time-to-event analyses using Cox proportional hazards. Results Median absolute lymphocyte count at baseline and nadir were 1.80 [interquartile range (IQR), 1.45-2.32] k/µL and 0.26 (IQR, 0.18-0.36) k/µL, respectively, and 31% developed treatment-related grade 4 lymphopenia. Median neutrophil-lymphocyte ratio at baseline and nadir were 2.34 (IQR, 1.68-3.30) and 8.80 (IQR, 5.86-12.68), respectively. Estimates of overall survival, local failure-free survival, distant metastasis-free survival (DMFS), and freedom from colostomy at 5 years were 87%, 86%, 82%, and 88%, respectively. Baseline and nadir absolute lymphocyte count were not associated with selected outcomes on univariate analysis. On multivariable analysis, factors independently associated with death included T3-T4 disease, HIV-positive status, treatment break, and baseline neutrophil-lymphocyte ratio >3. Baseline neutrophil-lymphocyte ratio showed a trend toward association with distant progression or death (P=0.07). The 5-year overall survival estimates for patients with baseline neutrophil-lymphocyte ratios ≤3 and >3 were 92.3% and 80.6%, respectively. Conclusions Lymphopenia during and after chemoradiation for anal cancer is common but does not appear to be associated with worse survival, recurrence, or metastases. However, elevated baseline neutrophil-lymphocyte ratio was independently associated with overall survival, local recurrence-free survival, and DMFS. Further studies are needed to determine the clinical utility of baseline neutrophil-lymphocyte ratio to guide treatment and follow-up.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Craig A Messick
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew C Cagley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Van K Morris
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Marref I, Romain G, Jooste V, Vendrely V, Lopez A, Faivre J, Gerard JP, Bouvier AM, Lepage C. Outcomes of anus squamous cell carcinoma. Management of anus squamous cell carcinoma and recurrences. Dig Liver Dis 2021; 53:1492-1498. [PMID: 34193366 DOI: 10.1016/j.dld.2021.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little is known about the management of squamous cell carcinoma of the anal canal and its recurrence at a population level. The aim of this study was to draw a picture of management, recurrence and survival in squamous cell carcinoma of the anal canal. MATERIAL AND METHODS The 5-year probability of recurrences was estimated using the cumulative incidence function to consider competing risks of death. Net survival was estimated and a multivariate survival analysis was performed. The study was conducted using data of the Burgundy Digestive Cancer Registry. Overall, 273 squamous cell carcinomas of the anal canal registered between 1998 and 2014 were considered. RESULTS Overall, 80% of patients were treated with curative intent. Of these, 61% received chemoradiotherapy, 35% received radiotherapy and 4% received abdominoperineal resection alone. After these treatments, for cure the 5-year cumulative recurrence rate was 27% overall; it was 20% after chemoradiotherapy and 38% after radiotherapy. Five-year net survival was 71% overall; it was 81% after chemoradiotherapy and 55% after radiotherapy. CONCLUSIONS AND RELEVANCE Chemoradiotherapy was highly effective in routine practice. We confirm that it is difficult to distinguish between persistent active disease and local inflammation due to radiotherapy. Squamous cell carcinoma of the anal canal recurrences remains a substantial problem, highlighting the interest of prolonged surveillance. Aggressive management of recurrences may be beneficial.
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Affiliation(s)
- Imène Marref
- Digestive Cancer Registry of Burgundy, INSERM UMR 1231 EPICAD, University of Bourgogne-Franche Comté, University Hospital of Dijon, Dijon, France
| | - Gaëlle Romain
- Digestive Cancer Registry of Burgundy, INSERM UMR 1231 EPICAD, University of Bourgogne-Franche Comté, University Hospital of Dijon, Dijon, France
| | - Valerie Jooste
- Digestive Cancer Registry of Burgundy, INSERM UMR 1231 EPICAD, University of Bourgogne-Franche Comté, University Hospital of Dijon, Dijon, France
| | - Véronique Vendrely
- CHU de Bordeaux, Haut-Lévêque Hospital, Department of Radiotherapy, Pessac, 33604, France
| | - Anthony Lopez
- Gastroenterology and Hepatology Department, Centre Hospitalo-Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
| | - Jean Faivre
- Digestive Cancer Registry of Burgundy, INSERM UMR 1231 EPICAD, University of Bourgogne-Franche Comté, University Hospital of Dijon, Dijon, France
| | | | - Anne-Marie Bouvier
- Digestive Cancer Registry of Burgundy, INSERM UMR 1231 EPICAD, University of Bourgogne-Franche Comté, University Hospital of Dijon, Dijon, France
| | - Côme Lepage
- Digestive Cancer Registry of Burgundy, INSERM UMR 1231 EPICAD, University of Bourgogne-Franche Comté, University Hospital of Dijon, Dijon, France; CHU de Bordeaux, Haut-Lévêque Hospital, Department of Radiotherapy, Pessac, 33604, France; Gastroenterology and Hepatology Department, Centre Hospitalo-Universitaire de Nancy, Vandoeuvre-lès-Nancy, France; Department of Radiotherapy, Centre A Lacassagne, Nice, France; Department of Hepatogastroenterology and Digestive Oncology and Gastroenterology, , University Hospital of Dijon, University of Bourgogne-Franche Comté, 14 Rue Paul Gaffarel, 21000 Dijon, France.
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11
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The role of haematological parameters in predicting the response to radical chemoradiotherapy in patients with anal squamous cell cancer. Radiol Oncol 2021; 55:449-458. [PMID: 34626531 PMCID: PMC8647797 DOI: 10.2478/raon-2021-0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background Historically, the treatment of choice for anal cancer had been abdominoperineal resection (APR). Radical radiotherapy with concurrent 5-fluorouracil plus mitomycin C chemotherapy was later established as standard therapy, although with a failure rate of 20–30%. The aim of this study was to evaluate the outcomes after radical chemoradiotherapy (CRT), prognostic and predictive factors and patterns of failure. Patients and methods This study included 47 patients treated with radical CRT for patohistologicaly confirmed anal squamous cell carcinoma. Analysed haematological parameters included: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and haemoglobin level. The final logistic regression model included treatment break period. Tumour response was assessed at 24 weeks from CRT completion. Follow-up was performed every 3 months during the first two years, and every 6 months thereafter. Results A complete clinical response (CR) was detected in 30 patients (63.8%). Patients who did not achieve a 6-months CR and those who had a CR after 6 months but then relapsed were referred to surgical treatment. With combined CRT and surgical salvage treatment the CR rate was 80.9%. Patients with CR after 6 months had significantly longer disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS). A significant effect on the 6-month response was confirmed for PLR (p = 0.03). Conclusions Important prognostic factors associated with CR were baseline haemoglobin level and period of treatment interruptions. Potential haematological prognostic factors could be PLR and NLR, which can be routinely determined by low-cost and minimally invasive methods.
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Radiotherapy with Intensity-Modulated (IMRT) Techniques in the Treatment of Anal Carcinoma (RAINSTORM): A Multicenter Study on Behalf of AIRO (Italian Association of Radiotherapy and Clinical Oncology) Gastrointestinal Study Group. Cancers (Basel) 2021; 13:cancers13081902. [PMID: 33920873 PMCID: PMC8071256 DOI: 10.3390/cancers13081902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/01/2021] [Accepted: 04/12/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Concurrent chemo-radiotherapy is the standard treatment in anal cancer. Intensity-modulated radiotherapy (IMRT) was proved to reduce severe, acute and late toxicities. Moreover, IMRT techniques allow for the planning and delivery of a simultaneous integrated boost (SIB), with a differential dose per fraction given to selected sub-regions during the same treatment session. This boost modality provides the chance to employ a dose-painted approach with a reduction in overall treatment time that could result in a potential clinical advantage. Since a large variability in dose prescription to the primary tumor and elective or involved lymph nodes can be found in available guidelines and clinical practice, a multicenter analysis was conducted to evaluate the pattern of care and the impact of radiotherapy parameters on clinical outcomes for anal cancer patients treated with IMRT techniques within a national cohort. Abstract A multi-institutional retrospective study was conducted to evaluate the pattern of care and clinical outcomes of anal cancer patients treated with intensity-modulated radiotherapy (IMRT) techniques. In a cohort of 987 patients, the clinical complete response (CR) rate (beyond 6 months) was 90.6%. The 3-year local control (LC) rate was 85.8% (95% CI: 84.4–87.2), and the 3-year colostomy-free survival (CFS) rate was 77.9% (95% CI: 76.1–79.8). Three-year progression-free survival (PFS) and overall survival (OS) rates were 80.2% and 88.1% (95% CI: 78.8–89.4) (95% CI: 78.5–81.9), respectively. Histological grade 3 and nodal involvement were associated with lower CR (p = 0.030 and p = 0.004, respectively). A statistically significant association was found between advanced stage and nodal involvement, and LC, CFS, PFS, OS and event-free survival (EFS). Overall treatment time (OTT) ≥45 days showed a trend for a lower PFS (p = 0.050) and was significantly associated with lower EFS (p = 0.030) and histological grade 3 with a lower LC (p = 0.025). No statistically significant association was found between total dose, dose/fraction and/or boost modality and clinical outcomes. This analysis reports excellent clinical results and a mild toxicity profile, confirming IMRT techniques as standard of care for the curative treatment of anal cancer patients. Lymph node involvement and histological grade have been confirmed as the most important negative prognostic factors.
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Jethwa KR, Day CN, Sandhyavenu H, Gonuguntla K, Harmsen WS, Breen WG, Routman DM, Garda AE, Hubbard JM, Halfdanarson TR, Neben-Wittich MA, Merrell KW, Hallemeier CL, Haddock MG. Intensity modulated radiotherapy for anal canal squamous cell carcinoma: A 16-year single institution experience. Clin Transl Radiat Oncol 2021; 28:17-23. [PMID: 33732911 PMCID: PMC7943964 DOI: 10.1016/j.ctro.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction To report long-term efficacy and adverse events (AEs) associated with intensity modulated radiotherapy (IMRT) for patients with anal canal squamous cell carcinoma (ASCC). Materials and methods This was a retrospective review of patients with ASCC who received curative-intent IMRT and concurrent chemotherapy (98%) between 2003 and 2019. Overall survival (OS), colostomy-free survival (CFS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. The cumulative incidence of local recurrence (LR), locoregional recurrence (LRR), and distant metastasis (DM) were reported. Acute and late AEs were recorded per National Cancer Institute Common Terminology Criteria for AEs. Results 127 patients were included. The median patient age was 63 years (interquartile range [IQR] 55-69) and 79% of patients were female. 33% of patients had T3-4 disease and 68% had clinically involved pelvic or inguinal lymph nodes (LNs).The median patient follow-up was 47 months (IQR: 28-89 months). The estimated 4-year OS, CFS, and PFS were 81% (95% confidence interval [CI]: 73%-89%), 77% (95% CI: 68%-86%), and 78% (95% CI: 70%-86%), respectively. The 4-year cumulative incidences of LR, LRR, and DM were 3% (95% CI: 1%-9%), 9% (95% CI: 5%-17%), and 10% (95% CI: 6%-18%), respectively. Overall treatment duration greater than 39 days was associated with an increased risk of LRR (Hazard Ratio [HR]: 5.2, 95% CI: 1.4-19.5, p = 0.015). The most common grade 3+ acute AEs included hematologic (31%), gastrointestinal (GI) (17%), dermatologic (16%), and pain (15%). Grade 3+ late AEs included: GI (3%), genitourinary (GU) (2%), and pain (1%). Current smokers were more likely to experience grade 3+ acute dermatologic toxicity compared to former or never smokers (34% vs. 7%, p < 0.001). Conclusions IMRT was associated with favorable toxicity rates and long-term efficacy. These data support the continued utilization of IMRT as the preferred treatment technique for patients with ASCC.
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Key Words
- 3DCRT, 3-dimensional conformal radiotherapy
- 5-FU, 5-fluorouracil
- ACT II, United Kingdom Anal Cancer Trial II
- AE, adverse events
- ASCC, anal canal squamous cell carcinoma
- Anal cancer
- BED, biologically effective dose
- CFS, colostomy-free survival
- CI, confidence interval
- CRT, chemoradiotherapy
- CTCAE v 4.0, common terminology criteria for adverse events version 4.0
- CTV, clinical target volume
- DM, distant metastasis
- DP-IMRT, dose-painted intensity modulated radiotherapy
- DVH, dose-volume histogram
- G, grade
- GI, gastrointestinal
- GU, genitourinary
- HIV, human immunodeficiency virus
- HR, hazard ratio
- IMRT
- IMRT, intensity modulated radiotherapy
- IQR, interquartile range
- LN, lymph node
- LR, local recurrence
- LRR, locoregional recurrence
- MMC, mitomycin-C
- OS, overall survival
- PFS, progression-free survival
- PTV, planning target volume
- RT, radiotherapy
- RTOG, Radiation Therapy Oncology Group
- Radiation
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States.,Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Courtney N Day
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | | | - Karthik Gonuguntla
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joleen M Hubbard
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | | | | | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
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Sexual Function, Quality of Life, and Mood After Radiation Therapy in Patients with Anal Cancer. J Gastrointest Cancer 2020; 51:204-210. [PMID: 30980294 DOI: 10.1007/s12029-019-00233-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE/OBJECTIVE(S) Definitive chemoradiation (CRT) results in high cure rates of anal cancer, with advanced radiation (RT) techniques improving toxicity. However, there is limited data regarding these patients' sexual function (SF), quality of life (QOL), and mood. We hypothesized that anal cancer treatment would result in detrimental effects on SF, QOL, and mood. MATERIALS/METHODS We prospectively surveyed patients with anal cancer treated with definitive CRT. We assessed SF for women with the Female Sexual Function Index (FSFI) and for men with the International Index of Erectile Function (IIEF). For all patients, we assessed QOL using EORTC QLQ-C30 and CR29 and mood using the Hospital Anxiety and Depression Scale (HADS). We reported descriptive statistics for SF, QOL, and mood and used univariate analysis to evaluate predictors of SF for women. RESULTS Of 50 eligible patients, 84% completed the surveys. Median time from RT until survey was 36 months (1-97 months). Women (n = 34) reported poor SF overall (mean FSFI score = 15, scale 2-36, standard deviation (SD) 10.4). Most women reported poor SF related to satisfaction, desire, orgasm, arousal, pain, and lubrication. Men (n = 8) also had poor overall satisfaction (mean IIEF score = 6.1, scale 2-10, SD 3.6). Men reported poor erectile function and lower satisfaction with intercourse. Mean QLQ-C30 QOL score was 86.5 (SD 16.3). Results from EORTC QLQ-CR-20 demonstrated patients experienced poor sexual interest. Per HADS, 2.5% reported depression and 18% anxiety. CONCLUSION Patients with anal cancer experience sexual dysfunction after RT, with QOL and mood symptoms similar to patients with other cancers. Our data support the need for ongoing efforts to understand and address issues with SF, QOL, and mood following RT for these patients.
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Dell'Acqua V, Surgo A, Arculeo S, Zerella MA, Bagnardi V, Frassoni S, Zampino MG, Ravenda PS, Rotundo MS, Kraja F, Kobiela J, Spychalski P, Fodor C, Gerardi MA, Cattani F, Bazani A, Petz W, Glynne-Jones R, Orecchia R, Leonardi MC, Jereczek-Fossa BA. Intensity-modulated radiotherapy (IMRT) in the treatment of squamous cell anal canal cancer: acute and early-late toxicity, outcome, and efficacy. Int J Colorectal Dis 2020; 35:685-694. [PMID: 32036405 DOI: 10.1007/s00384-020-03517-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To retrospectively review our experience on 84 patients with squamous cell anal canal cancer (SCAC) within 12 months after combined treatment with intensity-modulated RT (IMRT), in terms of acute and early-late toxicity, overall treatment time and interruptions, colostomy-free survival (CFS), and tumor response. METHODS Acute gastrointestinal (GI), genitourinary (GU), and cutaneous (CU) toxicities were assessed according to Common Toxicity Criteria for Adverse Events (CTCAE) version 4.03. Early-late toxicity was scored using the Radiation Therapy Oncology Group (RTOG) late radiation morbidity scoring system. Tumor response was evaluated with response evaluation criteria in solid tumors (RECIST) v1.1. RESULTS Acute toxicity for 84 subjects (100%): severe (≥ G3) GI and skin toxicity was observed in 4 (5%) and 19 patients (23%), respectively. Early-late toxicity for 73 subjects (87%): severe (≥ G3) GI and vulvo-vaginal toxicity was observed in 2 (3%) and 2 (3%) patients, respectively. No acute or early-late severe GU toxicity was reported. A treatment interruption occurred in 65 patients (77%). CFS was 96% (95% CI 89-99) at 6 months and 92% (95% CI 83-96) at 12 months. At 6 months complete response (CR), partial response (PR) and progressive disease (PD) was observed in 70 (83%), 3 (4%), and 7 patients (8%), respectively. At 12 months, CR was observed in 60 patients (81%); eleven patients (15%) experienced PD. CONCLUSION Our study showed an excellent clinical result and very low acute toxicity rates, confirming the IMRT as standard of care for curative treatment of anal cancer patients. The current trial was registered with the number IEO N87/11.
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Affiliation(s)
- Veronica Dell'Acqua
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Alessia Surgo
- Radiation Oncology Department, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Simona Arculeo
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Maria Alessia Zerella
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy.
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Maria Giulia Zampino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paola Simona Ravenda
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Maria Saveria Rotundo
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Fatjona Kraja
- Division of Oncology, University Hospital Centre "Mother Theresa", Rruga e Dibrës 372, 1000, Tirana, AL, Albania
| | - Jarek Kobiela
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Marii Skłodowskiej-Curie 3a, 80-210, Gdańsk, Poland
| | - Piotr Spychalski
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Marii Skłodowskiej-Curie 3a, 80-210, Gdańsk, Poland
| | - Cristiana Fodor
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | | | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Alessia Bazani
- Unit of Medical Physics, European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Wanda Petz
- Division of Gastrointestinal Surgery, European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | | | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Maria Cristina Leonardi
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
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Dosimetric comparison of organs at risk using different contouring guidelines for definition of the clinical target volume in anal cancer. Strahlenther Onkol 2020; 196:368-375. [PMID: 32016496 PMCID: PMC7089901 DOI: 10.1007/s00066-020-01587-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
Background There are different contouring guidelines for definition of the clinical target volume (CTV) for intensity-modulated radiation therapy (IMRT) of anal cancer (AC). We conducted a planning comparison study to evaluate and compare the dose to relevant organs at risk (OARs) while using different CTV definitions. Methods Twelve patients with a primary diagnosis of anal cancer, who were treated with primary chemoradiation (CRT), were selected. We generated four guideline-specific CTVs and subsequently planned target volumes (PTVs) on the planning CT scan of each patient. An IMRT plan for volumetric arc therapy (VMAT) was set up for each PTV. Dose parameters of the planned target volume (PTV) and OARs were evaluated and compared, too. Results The mean volume of the four PTVs ranged from 2138 cc to 2433 cc. The target volumes contoured by the authors based on the recommendations of each group were similar in the pelvis, while they differed significantly in the inguinal region. There were no significant differences between the four target volumes with regard to the dose parameters of the cranially located OARs. Conversely, some dose parameters concerning the genitals and the skin varied significantly among the different guidelines. Conclusion The four contouring guidelines differ significantly concerning the inguinal region. In order to avoid inguinal recurrence and to protect relevant OARs, further investigations are needed to generate uniform standards for definition of the elective clinical target volume in the inguinal region.
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de Meric de Bellefon M, Lemanski C, Castan F, Samalin E, Mazard T, Lenglet A, Demontoy S, Riou O, Llacer-Moscardo C, Fenoglietto P, Aillères N, Thezenas S, Debrigode C, Vieillot S, Gourgou S, Azria D. Long-term follow-up experience in anal canal cancer treated with Intensity-Modulated Radiation Therapy: Clinical outcomes, patterns of relapse and predictors of failure. Radiother Oncol 2019; 144:141-147. [PMID: 31809980 DOI: 10.1016/j.radonc.2019.11.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/02/2019] [Accepted: 11/14/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE To assess the long-term outcomes of patients with squamous cell carcinoma of the anal canal (SCCAC) treated with Intensity-Modulated Radiation Therapy (IMRT). MATERIAL AND METHODS From 2007 to 2015, 193 patients were treated by IMRT for SCCAC. Radiotherapy delivered 45 Gy in 1.8 Gy daily-fractions to the primary tumor and elective nodal areas, immediately followed by a boost of 14.4-20 Gy to the primary tumor and involved nodes. Concurrent chemotherapy with 5-FU-mitomycin (MMC) or cisplatin was added for locally advanced tumors. Survivals were estimated by Kaplan-Meier method. Locoregional (LR) relapses were precisely assessed. Prognostic factors were evaluated by uni- and multivariate analyses. Late toxicity was scored according to the Common Toxicity Criteria for Adverse Events v4.0. RESULTS Median follow-up was 70 months (range, 1-131). Forty-nine men (25%) and 144 women (75%) were analyzed. Median age was 62 years. Tumor stages were I, II, III and IV in 7%, 24%, 63% and 6% of cases, respectively. Chemotherapy was delivered in 167 patients (87%), mainly MMC (80%). Five-year OS, DFS, CFS and LR control rates were 74%, 68%, 66% and 85%, respectively. Forty-one patients (21%) had a relapse: 22 were LR, mostly in-field (68%). Predictors for LR failure were exclusive radiotherapy, chemotherapy lacking MMC and treatment breaks >3 days. Overall late toxicity ≥grade 2 occurred in 43% of patients, with 24% grade 3 and one case of grade 4 (hematuria). CONCLUSION CRT with IMRT assures excellent local control in locally advanced SCCAC with manageable long-term toxicity. Multicentric prospective trials are required to reinforce those results.
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Affiliation(s)
- Maïlys de Meric de Bellefon
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France.
| | - Claire Lemanski
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Florence Castan
- Biometrics Unit ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Emmanuelle Samalin
- Department of Medical Oncology, ICM, Montpellier Cancer Institute - University of Montpellier, INSERM U1194, IRCM, France
| | - Thibault Mazard
- Department of Medical Oncology, ICM, Montpellier Cancer Institute - University of Montpellier, INSERM U1194, IRCM, France
| | - Alexis Lenglet
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Sylvain Demontoy
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Olivier Riou
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Carmen Llacer-Moscardo
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Pascal Fenoglietto
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Norbert Aillères
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Simon Thezenas
- Biometrics Unit ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - Charles Debrigode
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, CHU Nîmes, France
| | - Sabine Vieillot
- Department of Radiation Oncology, Catalan Oncology Center, Perpignan, France
| | - Sophie Gourgou
- Biometrics Unit ICM, Montpellier Cancer Institute - University of Montpellier, France
| | - David Azria
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute - University of Montpellier, France
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Agarwal MS, Hitchcock KE, Morris CG, George TJ, Mendenhall WM, Zlotecki RA. Outcomes after intensity-modulated compared with 3-dimensional conformal radiotherapy with chemotherapy for squamous cell carcinoma of the anal canal. ACTA ACUST UNITED AC 2019; 26:e515-e521. [PMID: 31548820 DOI: 10.3747/co.26.4311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose We report our institution's treatment techniques, disease outcomes, and complication rates after radiotherapy for the management of anal canal carcinoma with intensity-modulated radiotherapy (imrt) and concurrent chemotherapy relative to prior cases managed with 3-dimensional conformal radiotherapy (3D-crt). Methods In a retrospective review of the medical records of 21 patients diagnosed with biopsy-proven stage i (23%), stage ii (27%), or stage iii (50%) squamous-cell carcinoma of the anal canal treated with curative chemotherapy and imrt between July 2009 and December 2014, patient outcomes were determined. Results for patients treated with 3D-crt by the same group were previously reported. The median initial radiation dose to the pelvic and inguinal nodes at risk was 45 Gy (range: 36-50.4 Gy), and the median total dose, including local anal canal primary tumour boost, was 59.4 Gy (range: 41.4-61.2 Gy). Patients received those doses over a median of 32 fractions (range: 23-34 fractions). Chemotherapy consisted of 2 cycles of concurrent fluorouracil-cisplatin (45%) or fluorouracil-mitomycin C (55%). Results Median follow-up was 3.1 years (range: 0.38-6.4 years). The mean includes a patient who died of septic shock at 38 days. The 3-year rates of overall survival, metastasis-free survival, locoregional control, and colostomy-free survival were 95%, 100%, 100%, and 100% respectively. No patients underwent abdominoperitoneal resection after chemoradiotherapy or required diverting colostomy during or after treatment. Those outcomes compare favourably with the previously published series that used 3D-crt with or without brachytherapy in treating anal canal cancers. Of the 21 patients in the present series, 10 (48%) experienced acute grade 3, 4, or 5 toxicities related to treatment. Conclusions The recommended use of imrt with concurrent chemotherapy as an improvement over 3D-crt for management of anal canal carcinoma achieves a high probability of local control and colostomy-free survival without excessive risk for acute or late treatment-related toxicities.
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Affiliation(s)
- M S Agarwal
- Department of Radiat ion Oncology, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - K E Hitchcock
- Department of Radiat ion Oncology, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - C G Morris
- Department of Radiat ion Oncology, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - T J George
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - W M Mendenhall
- Department of Radiat ion Oncology, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - R A Zlotecki
- Department of Radiat ion Oncology, University of Florida College of Medicine, Gainesville, FL, U.S.A
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Savoie MB, Laffan A, Brickman C, Daniels B, Levin A, Rowen T, Smith J, Van Blarigan EL, Hope TA, Berry-Lawhorn JM, Anwar M, Van Loon K. A multi-disciplinary model of survivorship care following definitive chemoradiation for anal cancer. BMC Cancer 2019; 19:906. [PMID: 31510960 PMCID: PMC6737598 DOI: 10.1186/s12885-019-6053-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
Following definitive chemoradiation for anal squamous cell carcinoma (ASCC), patients face a variety of chronic issues including: bowel dysfunction, accelerated bone loss, sexual dysfunction, and psychosocial distress. The increasing incidence of this disease, high cure rates, and significant long-term sequelae warrant increased focus on optimal survivorship care following definitive chemoradiation. In order to establish our survivorship care model for ASCC patients, a multi-disciplinary team of experts performed a comprehensive literature review and summarized best practices for the multi-disciplinary management of this unique patient population. We reviewed principle domains of our survivorship approach: (1) management of chronic toxicities; (2) sexual health; (3) HIV management in affected patients; (4) psychosocial wellbeing; and (5) surveillance for disease recurrence and survivorship care delivery. We provide recommendations for the optimization of survivorship care for ASCC patients can through a multi-disciplinary approach that supports physical and psychological wellness.
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Affiliation(s)
- Marissa B Savoie
- School of Medicine, University of California, San Francisco, USA
| | - Angela Laffan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Cristina Brickman
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, USA
| | - Bevin Daniels
- Department of Physical Therapy, University of California, San Francisco, USA
| | - Anna Levin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Psycho-Oncology, University of California, San Francisco, USA
| | - Tami Rowen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | - James Smith
- Department of Urology, University of California, San Francisco, USA
| | - Erin L Van Blarigan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Urology, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - J Michael Berry-Lawhorn
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA
| | - Mekhail Anwar
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA.
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA.
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Valvo F, Ciurlia E, Avuzzi B, Doci R, Ducreux M, Roelofsen F, Roth A, Trama A, Wittekind C, Bosset JF. Cancer of the anal region. Crit Rev Oncol Hematol 2019; 135:115-127. [DOI: 10.1016/j.critrevonc.2018.12.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 12/06/2018] [Accepted: 12/19/2018] [Indexed: 11/25/2022] Open
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Koerber SA, Seither B, Slynko A, Haefner MF, Krug D, Liermann J, Adeberg S, Herfarth K, Debus J, Sterzing F. Chemoradiation in female patients with anal cancer: Patient-reported outcome of acute and chronic side effects. TUMORI JOURNAL 2018; 105:174-180. [PMID: 30484384 DOI: 10.1177/0300891618811273] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION We evaluated acute and chronic side effects of 3D conformal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) in female patients with anal carcinoma and accessed correlations between dosimetric parameters and the considered toxicities. METHODS For 70 women with anal cancer treated at our department, acute and chronic side effects and quality of life (QoL) were evaluated with questionnaires using the Common Terminology Criteria for Adverse Events (CTCAE v. 4.0.) and Late Effects in Normal Tissue, Subjective, Objective Management and Analytic Scales (LentSoma) before, during, and after the treatment. RESULTS Forty-seven out of 70 (67%) patients completed the questionnaire and were enrolled in the study. Only poor urinary stream, loss of pubic hair during chemoradiation, and chronic vaginal dryness were observed more frequently in the 3D-CRT group compared to the IMRT group (univariable logistic regression p = .032, p = .04, p = .049, respectively). After the treatment, 43% in the 3D-CRT group and 29% in the IMRT group reported a severe loss of QoL. A higher proportion among the patients receiving a genital V20 ⩾35% showed grade 1-3 side effects such as chronic dyspareunia ( p = .035; Fisher exact test). CONCLUSION Our results suggest that the use of IMRT decreases acute and chronic adverse effects although reduced QoL also occurred in the IMRT group. These effects are likely to be underreported in retrospective studies using physician-reported outcome measures.
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Affiliation(s)
- Stefan A Koerber
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Ben Seither
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alla Slynko
- 4 Institute of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Matthias F Haefner
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - David Krug
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jakob Liermann
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Sebastian Adeberg
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Klaus Herfarth
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juergen Debus
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Florian Sterzing
- 1 Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,3 National Center of Radiation Oncology (NCRO), Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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Dapper H, Oechsner M, Hirche C, Münch S, Sauter C, Borm K, Peeken JC, Combs SE, Habermehl D. Dosimetric comparison of different radiation techniques (IMRT vs. 3-dimensional) of the "true" (deep) ano-inguinal lymphatic drainage of anal cancer patients. Radiat Oncol 2018; 13:227. [PMID: 30466454 PMCID: PMC6249729 DOI: 10.1186/s13014-018-1174-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/06/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction The ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Currently, there are no recommendations for an inclusion of the ‘true’ AILD in the clinical target volume (CTV) of definitive chemoradiation for anal cancer patients. To estimate the relevance of inguinal recurrence, we compared the incidental dose to the AILD in anal cancer (AC) patients who were treated either with Volumetric Arc Therapy – Intensity Modulated Radiation Therapy (VMAT-IMRT) or conventional 3D-radiation technique. Methods One VMAT-IMRT-plans and one 3D-plans were calculated on the same target volumes and identical dose prescription in ten patients. We defined the volume of the AILD on the planning CT-scans based on the information of new fluorescence methods. Furthermore, we defined several anatomical subvolumes of interest inside the AILD. We examined and compared absolute and relative dosimetric parameters of the AILD and different anatomical subunits. Results The Dmean of the AILD was 40 Gy in the 3D-group and 38 Gy in the IMRT-group. Dmean and Dmedian as well as the V30Gy of the AILD and all subvolumes of the caudal AILD were significant higher using 3D-RT compared to IMRT. Even though the absolute differences were small, in the caudal aspect of the ano-inguinal lymphatic drainage the V30Gy could be more than 10% less with VMAT-IMRT. Conclusions 3D-RT was slightly superior to IMRT in terms of dose coverage of the AILD. However, the absolute differences were very small. Some relevant caudal parts of the AILD received an insufficient dose for treating potential micrometastases. Particularly in high-risk situations, this may lead to inguinal recurrence and therefore the true deep AILD should be included into the target volume in high risk patients.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Hirche
- Department for Hand-, Plastic and Reconstructive Surgery, Burn Centre, BG-Trauma Centre Ludwigshafen/Rhine, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christina Sauter
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany.,Deutsches Konsortium für translationale Krebsforschung (DKTK), Partner SiTe Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
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Kin C. So Now My Patient Has Squamous Cell Cancer: Diagnosis, Staging, and Treatment of Squamous Cell Carcinoma of the Anal Canal and Anal Margin. Clin Colon Rectal Surg 2018; 31:353-360. [PMID: 30397394 DOI: 10.1055/s-0038-1668105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Squamous cell carcinomas of the anal canal and the anal margin are rare malignancies that are increasing in incidence. Patients with these tumors often experience delayed treatment due to delay in diagnosis or misdiagnosis of the condition. Distinguishing between anal canal and anal margin tumors has implications for staging and treatment. Chemoradiation therapy is the mainstay of treatment for anal canal squamous cell, with abdominoperineal resection reserved for salvage treatment in cases of persistent or recurrent disease. Early anal margin squamous cell carcinoma can be treated with wide local excision, but more advanced tumors require a combination of chemoradiation therapy and surgical excision.
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Affiliation(s)
- Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Pan YB, Maeda Y, Wilson A, Glynne-Jones R, Vaizey CJ. Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review. Acta Oncol 2018; 57:1427-1437. [PMID: 30264638 DOI: 10.1080/0284186x.2018.1503713] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There is a paucity of data on incidence and mechanisms of long-term gastrointestinal consequences after chemoradiotherapy for anal cancer. Most of the adverse effects reported were based on traditional external beam radiotherapy whilst only short-term follow-ups have been available for intensity-modulated radiotherapy, and there is lack of knowledge about consequences of dose-escalation radiotherapy. METHOD A systematic literature review. RESULTS Two thousand nine hundred and eighty-five titles (excluding duplicates) were identified through the search; 130 articles were included in this review. The overall incidence of late gastrointestinal toxicity was reported to be 7-64.5%, with Grade 3 and above (classified as severe) up to 33.3%. The most commonly reported late toxicities were fecal incontinence (up to 44%), diarrhea (up to 26.7%), and ulceration (up to 22.6%). Diarrhea, fecal incontinence and buttock pain were associated with lower scores in radiotherapy specific quality of life scales (QLQ-CR29, QLQ-C30, and QLQ-CR38) compared to healthy controls. Intensity-modulated radiation therapy appears to reduce late toxicity. CONCLUSION Late gastrointestinal toxicities are common with severe toxicity seen in one-third of the patients. These symptoms significantly impact on patients' quality of life. Prospective studies with control groups are needed to elucidate long-term toxicity.
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Affiliation(s)
- Yi Bin Pan
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Longhua Hospital, Shanghai University of TCM, Shanghai, China
| | - Yasuko Maeda
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Imperial College London, London, UK
| | - Ana Wilson
- Imperial College London, London, UK
- Wolfson Unit of Endoscopy, St. Mark’s Hospital, Harrow, UK
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Peiffert D, Baumann AS, Serre AA, Vendrely V, Rouard N, Faivre JC, Vogin G. [Anal canal cancer: In the era of intensity-modulated radiotherapy, outstanding issues]. Cancer Radiother 2018; 22:509-514. [PMID: 30181029 DOI: 10.1016/j.canrad.2018.07.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/15/2018] [Indexed: 02/07/2023]
Abstract
Intensity-modulated radiotherapy makes possible to optimize the irradiation and spare normal tissues. The toxicity remains important with concomitant chemotherapy often associated. The improvement of MRI and PET-CT define more precisely the target volumes, which need a higher dose, but necessitates to respect the rules of contouring. The treatment is uniform whatever the stage but should be individualized based on clinical stage and tumor response. New paradigms concern biology, staging, volumes and doses, fractionation and combined treatments.
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Affiliation(s)
- D Peiffert
- Service de radiothérapie, institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France; EA 4360 Apemac, université de Lorraine, 9, avenue de la Forêt-de-Haye, 54500 Nancy, France.
| | - A S Baumann
- Service de radiothérapie, institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - A A Serre
- Service de radiothérapie, institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - V Vendrely
- Service de radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - N Rouard
- Hôpital Édouard-Hériot, 69000 Lyon, France
| | - J C Faivre
- Service de radiothérapie, institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - G Vogin
- Service de radiothérapie, institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
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Jones CM, Adams R, Downing A, Glynne-Jones R, Harrison M, Hawkins M, Sebag-Montefiore D, Gilbert DC, Muirhead R. Toxicity, Tolerability, and Compliance of Concurrent Capecitabine or 5-Fluorouracil in Radical Management of Anal Cancer With Single-dose Mitomycin-C and Intensity Modulated Radiation Therapy: Evaluation of a National Cohort. Int J Radiat Oncol Biol Phys 2018; 101:1202-1211. [PMID: 29859793 DOI: 10.1016/j.ijrobp.2018.04.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE Chemoradiation therapy (CRT) with mitomycin C (MMC) and 5-fluorouracil (5-FU) is established as the standard of care for the radical treatment of patients with anal squamous cell carcinoma (ASCC). The use of the oral fluoropyrimidine-derivative capecitabine is emerging as an alternative to 5-FU despite limited evidence of its tolerability and toxicity. METHODS AND MATERIALS A national cohort evaluation of ASCC management within the United Kingdom National Health Service was undertaken from February to July 2015. The toxicity rates were prospectively recorded. For the present analysis, we report data from ASCC patients who underwent intensity modulated RT and a single dose of MMC with either 5-FU (5-FU/MMC) or capecitabine (capecitabine/MMC). All were treated with radical intent and intensity modulated radiation therapy (IMRT) was delivered in accordance with UK guidance. RESULTS Of the 242 patients received from 40 centers across the United Kingdom, 147 met the inclusion criteria; 52 of whom were treated with capecitabine/MMC and 95 with 5-FU/MMC. No treatment-related deaths and no overall difference were found in the proportion of patients experiencing any grade ≥3 toxicity between the capecitabine and 5-FU groups (45% vs 55%; P = .35). However, significantly fewer patients in the capecitabine/MMC group experienced grade 3 hematologic toxicity (4% vs 27%; P = .001). A lower proportion of patients completed their planned chemotherapy course in the capecitabine cohort, although this did not reach statistical significance (81% vs 90%; P = .21). The median RT duration was 38 days (interquartile range 38-39) for both groups. No difference was found in the 1-year oncologic outcomes. CONCLUSIONS Capecitabine/MMC resulted in similar levels of grade 3/4 toxicity overall compared with 5-FU/MMC as CRT for ASCC, although differences were found in the patterns of observed toxicities, with less hematologic toxicity with capecitabine. Further studies of capecitabine/MMC are required to understand the acute toxicity profile and long-term oncologic outcomes of this combination with intensity modulated RT for ASCC.
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Affiliation(s)
- Christopher M Jones
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom; Radiotherapy Research Group, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard Adams
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; Velindre Hospital, Cardiff, United Kingdom
| | - Amy Downing
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom
| | - Rob Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Mark Harrison
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Maria Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - David Sebag-Montefiore
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom; Radiotherapy Research Group, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Duncan C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Rebecca Muirhead
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Oxford, United Kingdom.
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Haque W, Verma V, Butler EB, Teh BS. Utilization of intensity modulated radiation therapy for anal cancer in the United States. J Gastrointest Oncol 2018; 9:466-477. [PMID: 29998012 DOI: 10.21037/jgo.2018.03.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Chemoradiotherapy for anal cancer (AC) can incur substantial treatment-related toxicities. Whereas radiotherapy (RT) for AC has historically been delivered with two- or three-dimensional conformal RT (2D/3DCRT) techniques, intensity-modulated RT (IMRT) is associated with improved target conformality and lower doses to organs-at-risk (OARs). This is the first investigation to date evaluating trends of IMRT utilization in the United States. Methods The National Cancer Data Base (NCDB) was queried [2004-2015] for AC patients receiving definitive chemoradiotherapy with a defined RT technique (3DCRT versus IMRT). Following analysis based on temporal trends, multivariate logistic regression determined factors associated with receipt of IMRT. Secondarily, Kaplan-Meier analysis compared OS between the 3DCRT and IMRT groups, and Cox proportional hazards modeling determined variables associated with OS. Results Altogether, 11,396 patients met study criteria; 1,288 (11%) were treated with 3DCRT and 10,108 (89%) with IMRT. Temporally, utilization of IMRT rose significantly, from 28% in 2004 to 96% in 2015, corresponding with a progressive decrease in 3DCRT usage. IMRT was more likely delivered in node-positive disease, at academic centers, and in southern/western regions (P<0.05 for all). T3-4 disease was less likely to receive IMRT (P<0.05). As expected, there were no OS differences based on RT technique (P=0.402). Predictors of worse OS included advancing age, male gender, increasing comorbidities, advanced T-stage, and nodal positivity (P<0.05 for all). In addition to racial- and insurance-related factors, receipt of therapy at academic centers independently predicted for improved OS (P<0.05 for all). Conclusions Based on findings from this large, contemporary dataset, IMRT is now the most widely utilized RT technique for AC, and 3DCRT is used in a very small minority of patients. IMRT utilization is impacted by multiple characteristics, such as disease- and regional-related factors. These observations have implications for payers and insurance coverage; improved survival at academic centers has ramifications for patient counseling.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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Hyperfractionated Accelerated Reirradiation for Patients With Recurrent Anal Cancer Previously Treated With Definitive Chemoradiation. Am J Clin Oncol 2018; 41:632-637. [DOI: 10.1097/coc.0000000000000338] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dapper H, Habl G, Hirche C, Münch S, Oechsner M, Mayinger M, Sauter C, Combs SE, Habermehl D. Dosimetric quantification of the incidental irradiation of the 'true' (deep) ano-inguinal lymphatic drainage of anal cancer patients not described in conventional contouring guidelines. Acta Oncol 2018; 57:825-830. [PMID: 29297232 DOI: 10.1080/0284186x.2017.1415459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Findings from fluorescence methods give us new information about anatomical conditions of the AILD. Current contouring guidelines do not advise the inclusion of the 'true' AILD into the clinical target volume (CTV). Aim of this work was the retrospective analysis of the incidental dose to the AILD in an anal cancer (AC) patient cohort who underwent definitive chemoradiation (CRT) therapy with Volumetric Arc Therapy - Intensity Modulated Radiation Therapy (VMAT-IMRT). METHODS VMAT-IMRT plans of 15 AC patients were analyzed. Based on findings from new fluorescence methods we created a new volume, the expected AILD. The examined dosimetric parameters were the minimal, maximal and mean dose and V10-V50 that were delivered to the AILD, respectively. RESULTS The median volume of AILD was 1047 cm³. Mean Dmin, Dmax and Dmean were 7.5 Gy, 58.9 Gy and 40.8 Gy for AILD. The clinical relevant dose of 30.0 Gray covered in mean 76% of the volume of the AILD, respectively. CONCLUSIONS Only 76% of the AILD-volume received at least an expected required treatment dose of 30 Gy incidentally. Concerning the low number of loco-regional relapses in AC patients after definitive CRT one has to balance increased side effects against a rigid oncological-anatomical interpretation of the local lymphatic drainage by including the AILD into the standard CTV.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Christoph Hirche
- Department for Hand-, Plastic and Rekonstructive Surgery, Burn Centre BG-Trauma Centre Ludwigshafen/RhineBG – Klinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Christina Sauter
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
- Institute for Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
- Institute for Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Neuherberg, Germany
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Intensity Modulated Radiation Therapy Versus Conventional Radiation for Anal Cancer in the Veterans Affairs System. Int J Radiat Oncol Biol Phys 2018; 102:109-115. [PMID: 30102186 DOI: 10.1016/j.ijrobp.2018.05.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 04/28/2018] [Accepted: 05/16/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE Compared with conventional radiation therapy, intensity modulated radiation therapy (IMRT) may reduce acute toxicity from anal cancer treatment, potentially leading to improved long-term outcomes. We analyze the effect of IMRT on short- and long-term outcomes among a large sample of US veterans. METHODS AND MATERIALS From a national Veterans Affairs database, we identified 779 patients (n = 403 conventional radiation therapy, n = 376 IMRT) with locally advanced anal squamous cell carcinoma diagnosed between 2000 and 2015 and treated with concurrent chemoradiation therapy. Radiation treatment planning and dosimetric constraints were not standardized across patients. We analyzed the effect of IMRT on short-term outcomes (acute toxicity, treatment breaks, and incomplete chemotherapy) and long-term outcomes (survival and ostomy placement) in multivariable logistic regression, Fine-Gray, and frailty models, adjusting for potential confounders. RESULTS IMRT was associated with decreased radiation treatment breaks ≥5 days (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.37-0.91; P = .02), increased rates of receiving 2 cycles of mitomycin C chemotherapy (OR 2.04; 95% CI 1.22-3.45; P = .007), increased rates of receiving 2 cycles of any chemotherapy (OR 3.45; 95% CI 1.82-6.25; P < .001), and decreased risk of ostomy related to tumor recurrence or progression (subdistribution hazard ratio 0.60; 95% CI 0.37-0.99; P = .045). IMRT was not associated with a decrease in grade 3 to 4 hematologic toxicity (P = .79), hospitalization for gastrointestinal toxicity (P = .59), or cancer-specific survival (P = 0.18). CONCLUSIONS Among a large sample of US veterans with anal cancer, IMRT was associated with higher rates of receiving 2 chemotherapy cycles, decreased radiation treatment breaks, and decreased rates of ostomy placement. IMRT appears to offer substantial benefits over conventional radiation therapy for patients undergoing concurrent chemoradiation therapy for anal cancer.
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Bagshaw HP, Sause WT, Gawlick U, Kim HT, Whisenant J, Cannon GM. Vulvar Recurrences After Intensity-modulated Radiation Therapy for Squamous Cell Carcinoma of the Anus. Am J Clin Oncol 2018; 41:492-496. [PMID: 27438690 DOI: 10.1097/coc.0000000000000322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The objective is to determine localregional control (LRC), distant metastasis free survival, disease-free survival, overall survival (OS), and toxicity for patients with squamous cell carcinoma of the anus treated with definitive chemotherapy and intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS We conducted a retrospective review of patients treated using IMRT for squamous cell carcinoma of the anus at our institution since 2005. Patients with local recurrences were identified and reviewed. The Kaplan-Meier curves were used for LRC and OS. RESULTS From 2005 to 2014, 52 patients were treated with IMRT-based chemoradiation for squamous cell carcinoma of the anus. Median dose to the primary tumor was 54 Gy. LRC, distant metastasis free survival, OS, and disease-free survival were 92.3%, 88.5%, 86.5%, and 84.6%, respectively, with a median follow-up of 20 months. Two local failures occurred at the anal primary site and 2 in the vulva. Despite subsequent palliative radiotherapy and chemotherapy, neither patient with a vulvar recurrence achieved disease control. CONCLUSIONS In a cohort of patients treated with IMRT-based chemoradiation, 2 vulvar recurrences were identified within the avoided external genitalia despite limited recurrence rates within the cohort overall. This experience suggests that for patients with a locally advanced primary tumor and bulky bilateral inguinal or pelvic disease, the in-transit vulvar dermal lymphatics may be at risk for subclinical involvement and subsequent recurrence. If substantiated by a similar pattern of recurrence at other institutions, the external genitalia may need to be reclassified from an avoidance structure to a clinical treatment volume in patients with locally advanced anal cancer.
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Affiliation(s)
| | | | | | - H Tae Kim
- Intermountain Colon & Rectal Surgery
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Ludmir EB, Kachnic LA, Czito BG. Evolution and Management of Treatment-Related Toxicity in Anal Cancer. Surg Oncol Clin N Am 2018; 26:91-113. [PMID: 27889040 DOI: 10.1016/j.soc.2016.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over the past several decades, clinical trials have demonstrated improved disease-related outcomes in the definitive treatment of anal cancer. Although treatment with radiation and concurrent chemotherapy results in high rates of cure, significant acute and late toxicities are seen. This review focuses on the evolution of treatment-related toxicity for anal cancer. Management of these adverse effects is reviewed, as are future directions in anal cancer treatment and their impact on toxicity.
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Affiliation(s)
- Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1422, Houston, TX 77030, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Suite B1034, Nashville, TN 37232, USA
| | - Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA.
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Dell'Acqua V, Kobiela J, Kraja F, Leonardi MC, Surgo A, Zerella MA, Arculeo S, Fodor C, Ricotti R, Zampino MG, Ravenda S, Spinoglio G, Biffi R, Bazani A, Luraschi R, Vigorito S, Spychalski P, Orecchia R, Glynne-Jones R, Jereczek-Fossa BA. Genital marginal failures after intensity-modulated radiation therapy (IMRT) in squamous cell anal cancer: no higher risk with IMRT when compared to 3DCRT. Med Oncol 2018; 35:59. [PMID: 29594584 DOI: 10.1007/s12032-018-1118-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/22/2018] [Indexed: 12/16/2022]
Abstract
Intensity-modulated radiotherapy (IMRT) is considered the preferred option in squamous cell canal cancer (SCAC), delivering high doses to tumor volumes while minimizing dose to surrounding normal tissues. IMRT has steep dose gradients, but the technique is more demanding as deep understanding of target structures is required. To evaluate genital marginal failure in a cohort of patients with non-metastatic SCAC treated either with IMRT or 3DCRT and concurrent chemotherapy, 117 patients with SCAC were evaluated: 64 and 53 patients were treated with IMRT and 3DCRT techniques, respectively. All patients underwent clinical and radiological examination during their follow-up. Tumor response was evaluated with response evaluation criteria in solid tumors v1.1 guideline on regular basis. All patients' data were analyzed, and patients with marginal failure were identified. Concomitant chemotherapy was administered in 97 and 77.4% of patients in the IMRT and 3DCRT groups, respectively. In the IMRT group, the median follow-up was 25 months (range 6-78). Progressive disease was registered in 15.6% of patients; infield recurrence, distant recurrence and both infield recurrence and distant recurrence were identified in 5, 4 and 1 patient, respectively. Two out of 64 patients (3.1%) had marginal failures, localized at vagina/recto-vaginal septum and left perineal region. In the 3DCRT group, the median follow-up was 71.3 months (range 6-194 months). Two out of 53 patients (3.8%) had marginal failures, localized at recto-vaginal septum and perigenital structures. The rate of marginal failures was comparable in IMRT and 3DCRT groups (χ2 test p = 0.85). In this series, the use of IMRT for the treatment of SCAC did not increase the rate of marginal failures offering improved dose conformity to the target. Dose constraints should be applied with caution-particularly in females with involvement of the vagina or the vaginal septum.
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Affiliation(s)
- V Dell'Acqua
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - J Kobiela
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdańsk, Poland
| | - F Kraja
- Division of Oncology, University Hospital Centre "Mother Theresa", Tirana, Albania
| | - M C Leonardi
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy.
| | - A Surgo
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - M A Zerella
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - S Arculeo
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - C Fodor
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - R Ricotti
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - M G Zampino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, Milan, Italy
| | - S Ravenda
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, Milan, Italy
| | | | - R Biffi
- Unit of Peritoneal Cancer Surgery, European Institute of Oncology, Milan, Italy
| | - A Bazani
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - R Luraschi
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - S Vigorito
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - P Spychalski
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdańsk, Poland
| | - R Orecchia
- Scientific Directorate, European Institute of Oncology, Milan, Italy
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, HA6 2RN, UK
| | - B A Jereczek-Fossa
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Martin D, Balermpas P, Winkelmann R, Rödel F, Rödel C, Fokas E. Anal squamous cell carcinoma - State of the art management and future perspectives. Cancer Treat Rev 2018; 65:11-21. [PMID: 29494827 DOI: 10.1016/j.ctrv.2018.02.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
Anal squamous cell carcinoma (ASCC) is associated with infection with high-risk strains of human papilloma virus (HPV) in 70-90% of cases and a rise in incidence has been observed in the last decades. Definitive chemoradiotherapy (CRT) using 5-fluorouracil and mitomycin C constitutes the standard treatment for localized disease, but about 30% of patients do not respond or relapse locally. Phase I/II trials testing targeted agents, such as epidermal-growth-factor receptor (EGFR) inhibitors, have failed to improve clinical outcome and resulted in increased toxicities. Modern imaging methods and biomarkers, also in the context of HPV status, should be further explored to improve patient stratification. In the present review, we will discuss the current clinical evidence and future perspectives in the management of ASCC. HPV-positive ASCC is more immunogenic with a higher density of tumor infiltrating lymphocytes that correlate with better response to CRT and more favorable prognosis compared to HPV-negative tumors. Immunotherapies including immune checkpoint inhibitors have brought new hope and promising results were recently demonstrated in metastatic ASCC. The addition of immunotherapies to CRT for localized disease is tested in early phase trials, and these results could have a profound impact on the way we treat ASCC in near future. Further research and novel approaches are expected to enhance our understanding of tumor biology and immunology, and improve patient stratification and treatment adaptation in the context of personalized medicine.
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Affiliation(s)
- Daniel Martin
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany
| | - Panagiotis Balermpas
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site: Frankfurt a. M., Germany
| | - Ria Winkelmann
- Senckenberg Institute for Pathology, University of Frankfurt, Germany
| | - Franz Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site: Frankfurt a. M., Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site: Frankfurt a. M., Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site: Frankfurt a. M., Germany.
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Chin AL, Pollom EL, Qian Y, Koong AC, Chang DT. Impact of Intensity-Modulated Radiotherapy on Health Care Costs of Patients With Anal Squamous Cell Carcinoma. J Oncol Pract 2017; 13:e992-e1001. [PMID: 29035618 PMCID: PMC6202035 DOI: 10.1200/jop.2017.024810] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Drivers of variation in the cost of care after chemoradiotherapy for the management of anal squamous cell carcinoma (SCC) have not been fully elucidated. We sought to characterize the direct and indirect impact of radiotherapy modality on health care costs among patients with anal SCC. PATIENTS AND METHODS A retrospective cohort study was performed using the 2014 linkage of the SEER-Medicare database. We identified 1,025 patients with anal SCC diagnosed between 2001 and 2011 and treated with chemoradiotherapy. Propensity score matching was used to balance baseline differences between patients treated with intensity-modulated radiotherapy (IMRT) and those treated with three-dimensional conformal radiotherapy (3D-CRT). Differences in total, cancer-attributable, and procedure-specific costs between groups were measured. RESULTS Radiation-related, patient out-of-pocket, and total costs in the 1-year period after radiotherapy start were all higher for the IMRT group than the 3D-CRT group (median total cost, $35,890 v $27,262, respectively; P < .001). Patients who received IMRT had lower cumulative costs associated with urgent hospitalizations and emergency department visits at both 9 months and 1 year after treatment start compared with a matched cohort of patients who received 3D-CRT (median, $711 v $4,957 at 1 year, respectively; P = .021). CONCLUSION Although total costs of care were higher for IMRT compared with 3D-CRT, primarily as a result of higher radiotherapy-specific costs, IMRT was associated with decreased unplanned health care utilization costs starting at 9 months after treatment start. Radiotherapy-centered episodes of care may need to encompass a longer time horizon to capture the full cost savings associated with more advanced radiation modalities.
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Affiliation(s)
- Alexander L. Chin
- Stanford Cancer Institute, Stanford, CA; and MD Anderson Cancer Center, Houston TX
| | - Erqi L. Pollom
- Stanford Cancer Institute, Stanford, CA; and MD Anderson Cancer Center, Houston TX
| | - Yushen Qian
- Stanford Cancer Institute, Stanford, CA; and MD Anderson Cancer Center, Houston TX
| | - Albert C. Koong
- Stanford Cancer Institute, Stanford, CA; and MD Anderson Cancer Center, Houston TX
| | - Daniel T. Chang
- Stanford Cancer Institute, Stanford, CA; and MD Anderson Cancer Center, Houston TX
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Concurrent paclitaxel, capecitabine, mitomycin C and pelvic radiation therapy for patients with squamous cell anal carcinoma. Cancer Chemother Pharmacol 2017; 80:623-629. [DOI: 10.1007/s00280-017-3408-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/26/2017] [Indexed: 10/19/2022]
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Peiffert D, Créhange G, Vendrely V, Baumann AS, Faivre JC, Huger S. Radiothérapie des cancers du canal anal. Cancer Radiother 2016; 20 Suppl:S183-8. [DOI: 10.1016/j.canrad.2016.07.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Amini A, Jones BL, Ghosh D, Schefter TE, Goodman KA. Impact of facility volume on outcomes in patients with squamous cell carcinoma of the anal canal: Analysis of the National Cancer Data Base. Cancer 2016; 123:228-236. [PMID: 27571233 DOI: 10.1002/cncr.30327] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 07/21/2016] [Accepted: 08/11/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Given the rarity of anal cancer and the technical aspects involved in radiation (RT) planning, the authors conducted a population-based analysis evaluating the impact of radiation oncology facility volume on overall survival (OS) in patients with squamous cell carcinoma (SCC) of the anal canal. METHODS The National Cancer Data Base (NCDB) was queried for patients with SCC of the anal canal who underwent RT. All patients were coded as having received their entire course of RT at the NCDB reporting facility. Facility volume was categorized into tertiles (low, intermediate, and high) and was based on the number of times a facility's unique identification code appeared. RESULTS In total, 13,550 patients were identified. Patients who received treatment at higher volume radiation oncology facilities had longer OS based on multivariate analysis (MVA) (hazard ratio, 0.81; 95% confidence interval [CI], 0.73-0.90; P < .001) and propensity score matching analysis (hazard ratio, 0.79; 95% CI, 0.69-0.91; P < .001). For patients who received treatment at low-volume, intermediate-volume, and high-volume centers, the 5-year OS rate was 70%, 72.2%, and 75.4%, respectively (P < .001). Compared with low/intermediate-volume radiation oncology centers, high-volume centers were more likely to treat patients with concurrent chemotherapy (odds ratio, 1.27; 95% CI, 1.07-1.51; P = .006) and less likely to have treatment delays leading to an RT duration of >45 days (odds ratio, 0.74; 95% CI, 0.69-0.80; P < .001). CONCLUSIONS Treatment at higher volume radiation oncology centers appears to be associated with improved OS in patients with SCC of the anal canal. These results likely reflect the relation between physician experience and delivery of high-quality RT, which perhaps is best evident in rare tumors such as anal SCC. Cancer 2017;123:228-236. © 2016 American Cancer Society.
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Affiliation(s)
- Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Bernard L Jones
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Debashis Ghosh
- Department of Biostatistics, University of Colorado School of Public Health, Aurora, Colorado
| | - Tracey E Schefter
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
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Blackcloud P, Dabela E, Grossman ME. Grade 4 radiation dermatitis presenting with full-thickness ulcerations of the groin after radiation therapy for anal squamous cell carcinoma (SCC): An example of the "bolus effect" of radiation therapy. JAAD Case Rep 2016; 1:389-91. [PMID: 27051789 PMCID: PMC4809404 DOI: 10.1016/j.jdcr.2015.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Paul Blackcloud
- Department of Dermatology, Columbia University, New York, New York
| | - Ellen Dabela
- Department of Dermatology, Columbia University, New York, New York
| | - Marc E Grossman
- Department of Dermatology, Columbia University, New York, New York
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Cost-effectiveness of screening for anal cancer using regular digital ano-rectal examinations in men who have sex with men living with HIV. J Int AIDS Soc 2016; 19:20514. [PMID: 26942721 PMCID: PMC4778406 DOI: 10.7448/ias.19.1.20514] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 01/10/2016] [Accepted: 01/28/2016] [Indexed: 11/23/2022] Open
Abstract
Introduction Anal cancer in men who have sex with men (MSM) living with HIV is an important issue but there are no consistent guidelines for how to screen for this cancer. In settings where screening with anal cytology is unavailable, regular anal examinations have been proposed in some guidelines but their cost-effectiveness is unknown. Methods Our objective was to estimate the cost-effectiveness of regular anal examinations to screen for anal cancer in HIV-positive MSM living in Australia using a probabilistic Markov model. Data sources were based on the medical literature and a clinical trial of HIV-positive MSM receiving an annual anal examination in Australia. The main outcome measures for calculating effectiveness were undiscounted and discounted (at 3%) lifetime costs, life years gained, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratio (ICER). Results Base-case analysis estimated the average cost of screening for and management of anal cancer ranged from $195 for no screening to $1,915 for lifetime annual screening of men aged ≥ 50. Screening of men aged ≥ 50 generated ICERs of $29,760 per QALY gained (for screening every four years), $32,222 (every three years) and $45,484 (every two years). Uncertainty for ICERs was mostly influenced by the cost (financially and decrease in quality of life) from a false-positive result, progression rate of anal cancer, specificity of the anal examination, the probability of detection outside a screening program and the discount rate. Conclusions Screening for anal cancer by incorporating regular anal examinations into routine HIV care for MSM aged ≥ 50 is most likely to be cost-effective by conventional standards. Given that anal pap smears are not widely available yet in many clinical settings, regular anal exams for MSM living with HIV to detect anal cancer earlier should be implemented.
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Abstract
BACKGROUND During the past decade there has been considerable progress in developing new radiation methods for cancer treatment. Pelvic radiotherapy constitutes the primary or (neo) adjuvant treatment of many pelvic cancers e.g., locally advanced cervical and rectal cancer. There is an increasing focus on late effects and an increasing awareness that patient reported outcomes (PROs) i.e., patient assessment of physical, social, psychological, and sexual functioning provides the most valid information on the effects of cancer treatment. Following cure of cancer allow survivors focus on quality of life (QOL) issues; sexual functioning has proved to be one of the most important aspects of concern in long-term survivors. METHODS An updated literature search in PubMed was performed on pelvic radiotherapy and female sexual functioning/dysfunction. Studies on gynaecological, urological and gastrointestinal cancers were included. The focus was on the period from 2010 to 2014, on studies using PROs, on potential randomized controlled trials (RCTs) where female sexual dysfunction (FSD) at least constituted a secondary outcome, and on studies reporting from modern radiotherapy modalities. RESULTS The literature search revealed a few RCTs with FSD evaluated as a PRO and being a secondary outcome measure in endometrial and in rectal cancer patients. Very limited information could be extracted regarding FSD in bladder, vulva, and anal cancer patients. The literature before and after 2010 confirms that pelvic radiotherapy, independent on modality, increases the risk significantly for FSD both compared to data from age-matched healthy control women and compared to data on patients treated by surgery only. There was only very limited data available on modern radiotherapy modalities. These are awaited during the next five years. Several newer studies confirm that health care professionals are still reluctant to discuss treatment induced sexual dysfunction with patients. CONCLUSIONS Pelvic radiotherapy has a persistent deteriorating effect on the vaginal mucosa impacting negatively on the sexual functioning in female cancer patients. Hopefully, modern radiotherapy modalities will cause less vaginal morbidity but results are awaited to confirm this assumption. Health care professionals are encouraged to address potential sexual dysfunction both before and after radiotherapy and to focus more on quality than on quantity.
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Affiliation(s)
- Pernille Tine Jensen
- 1 Department of Gynecology and Obstetrics, Odense University Hospital, 5000 Odense, Denmark ; 2 Department of Gynecology and Obstetrics, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Ligita Paskeviciute Froeding
- 1 Department of Gynecology and Obstetrics, Odense University Hospital, 5000 Odense, Denmark ; 2 Department of Gynecology and Obstetrics, Copenhagen University Hospital, 2100 Copenhagen, Denmark
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Prevention and Management of Radiation-induced Late Gastrointestinal Toxicity. Clin Oncol (R Coll Radiol) 2015; 27:656-67. [DOI: 10.1016/j.clon.2015.06.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 05/26/2015] [Accepted: 06/09/2015] [Indexed: 12/18/2022]
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Belgioia L, Vagge S, Agnese D, Garelli S, Murialdo R, Fornarini G, Chiara S, Gallo F, Bacigalupo A, Corvò R. Intensified intensity-modulated radiotherapy in anal cancer with prevalent HPV p16 positivity. World J Gastroenterol 2015; 21:10688-10696. [PMID: 26457030 PMCID: PMC4588092 DOI: 10.3748/wjg.v21.i37.10688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/13/2015] [Accepted: 07/18/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the toxicity and response of intensity-modulated radiotherapy schedule intensified with a simultaneous integrated boost in anal canal cancer.
METHODS: From March 2009 to March 2014, we retrospectively analyzed 41 consecutive patients treated with intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy for anal canal squamous cell carcinoma at our center. Radiotherapy was delivered via simultaneous integrated boost (SIB) technique by helical tomotherapy, and doses were adapted to two clinical target volumes according to the tumor-node-metastasis (TNM) stage: 50.6 Gy and 41.4 Gy in 23 fractions in T1N0, 52.8 Gy and 43.2 Gy in 24 fractions in T2N0, and 55 Gy and 45 Gy in 25 fractions in all patients with N positive and/or ≥ T3, respectively, to planning target volumes 1 and 2. The most common chemotherapy regimen was 5-fluorouracil and mitomycin-based. Human papilloma virus (HPV) p16 expression was performed by immunohistochemistry and evaluated in the majority of patients. Acute and late toxicity was scored according to CTCAe v 3.0 and RTOG scales.
RESULTS: The median follow-up was 30 mo (range: 12-71). Median age was 63 years (range 32-84). The stage of disease was: stage I in 2 patients, stage II in 13 patients, stage IIIA in 12 patients, and stage IIIB in 14 patients, respectively. Two patients were known to be HIV positive (4.9%). HPV p16 expression status was positive in 29/34 (85.3%) patients. The 4-year progression-free survival and overall survival in HPV-positive patients were 78% and 92%, respectively. Acute grade 3 skin and gastrointestinal toxicities were reported in 5% and 7.3% of patients, respectively; patients’ compliance to the treatment was good due to a low occurrence of severe acute toxicity, although treatment interruptions due to toxicity were required in 7.3% of patients. At 6 mo from end of treatment, 36/40 (90%) patients obtained complete response; during follow-up, 5 (13.8%) patients presented with disease progression (local or systemic).
CONCLUSION: In our experience, intensified SIB-IMRT with chemotherapy is very feasible in clinical practice, with excellent results in terms of overall survival and local control.
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Tang Y, Crane CH, Eng C, Minsky BD, Delclos ME, Krishnan S, Malatek D, Gould MS, Das P. Quality of life after intensity-modulated radiation therapy for anal cancer. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13566-015-0209-4] [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]
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Shridhar R, Shibata D, Chan E, Thomas CR. Anal cancer: current standards in care and recent changes in practice. CA Cancer J Clin 2015; 65:139-62. [PMID: 25582527 DOI: 10.3322/caac.21259] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Answer questions and earn CME/CNE The management of squamous cell carcinomas of the anal canal has evolved from surgery as first-line treatment to curative chemoradiation, with surgery reserved for salvage. Significant progress has been made in understanding how to most effectively deliver chemotherapy and reduce toxicity through advancements in radiation delivery. The purpose of this article is to review the multimodality approach to the diagnosis and management of anal cancer based on a review of the published data and in light of available guidelines.
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Affiliation(s)
- Ravi Shridhar
- Associate Professor, Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
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47
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Tozzi A, Cozzi L, Iftode C, Ascolese A, Campisi MC, Clerici E, Comito T, De Rose F, Fogliata A, Franzese C, Mancosu P, Navarria P, Tomatis S, Villa E, Scorsetti M. Radiation therapy of anal canal cancer: from conformal therapy to volumetric modulated arc therapy. BMC Cancer 2014; 14:833. [PMID: 25403766 PMCID: PMC4247214 DOI: 10.1186/1471-2407-14-833] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 10/30/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To appraise the role of volumetric modulated arc (RapidArc, RA) in the treatment of anal canal carcinoma (ACC). METHODS A retrospective analysis has been conducted on 36 patients treated with RA since 2009 comparing outcome against a group of 28 patients treated with conformal therapy (CRT). RA treatments were prescribed with SIB technique with 59.4 Gy to the primary tumor and nodes and 49.5 Gy to the elective nodes. CRT was sequentially delivered with 45 Gy to the pelvic target and a boost of 14.4 Gy to the primary tumor. RESULTS Median age of patients was 65 yrs for RA (59 yrs for CRT); 90% had Stage II-III (93% in the CRT group). No statistically significant differences were observed concerning survival or control. 5 yrs disease specific survival was 85.7% and 81.2%, loco-regional control was of 78.1% and 82.1% for RA and CRT respectively. RA treatments lead to lower incidence of higher grade of toxicity events (all retrospectively retrieved from charts as worse events). Grade 2-3 toxicity, compared to CRT, reduced from 89% to 68% for GI, from 39% to 33% for GU and from 82% to 75% for the skin. Late toxicity was as follows: 5/36 (14%) and 3/36 (8%) patients had G1 or G2 GI toxicity in the RA group (1/28 (4%) and 4/28 (14%) in the CRT group). GU late toxicity was observed only in 4/28 (14%) patients of the CRT group: 3/28 (11%) had G2 and 1/28 (4%) had G1. CONCLUSIONS RA treatments of ACC patients proved to be equally effective than CRT but it was associated to a reduction of toxicity.
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Affiliation(s)
| | - Luca Cozzi
- Department of Radiotherapy and Radiosurgery, Istituto Clinico Humanitas Cancer Center, Rozzano, Milan, Italy.
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Janssen S, Glanzmann C, Bauerfeind P, Stieb S, Studer G, Brown M, Riesterer O. Clinical experience of SIB-IMRT in anal cancer and selective literature review. Radiat Oncol 2014; 9:199. [PMID: 25199879 PMCID: PMC4261589 DOI: 10.1186/1748-717x-9-199] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 08/31/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To evaluate feasibility and outcome of our institutional SIB-IMRT schedule in patients with anal cancer and to selectively review the literature on different SIB-IMRT schedules. PATIENTS AND METHODS Between 01/08-06/13 25 patients with biopsy proven squamous cell anal cancer were treated in our institution with IMRT. Radiotherapy was delivered in two series using a SIB-IMRT schedule of 45 Gy/1.8 Gy to the primary tumor and adjacent pelvic lymph nodes and 38 Gy/1.52 Gy to elective nodes followed by an IMRT boost of 7×2 Gy = 14 Gy to the primary tumor and involved nodes (cumulative prescription dose: 59 Gy). RESULTS Mean follow-up was 20 months (range: 4-68). The 2-year-local control, colostomy-free survival, distant metastases-free survival and overall survival rates were 92%, 92%, 92%, and 88%, respectively. Grade 3 acute skin toxicity was observed in 6 patients (24%). No high grade gastrointestinal or urinary acute toxicity occurred. Four patients required more than one day of treatment interruption due to acute toxicity. No grade 3 or higher late sequelae were observed. CONCLUSION We present our institutional SIB-IMRT experience treating patients with anal cancer in two series using moderate single doses from 1.5-2.0 Gy. Our results, in terms of loco-regional outcome and toxicity, were comparable to other studies. The incidence of treatment interruptions was very low. Therefore this schedule appears to be safe for clinical use.
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Affiliation(s)
| | | | | | | | | | | | - Oliver Riesterer
- Departments of Radiation Oncology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.
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Scher ED, Ahmed I, Yue NJ, Jabbour SK. Technical aspects of radiation therapy for anal cancer. J Gastrointest Oncol 2014; 5:198-211. [PMID: 24982768 DOI: 10.3978/j.issn.2078-6891.2014.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/22/2014] [Indexed: 01/26/2023] Open
Abstract
Historically treated with surgery, current practice recommends anal carcinoma to be treated with a combination of chemotherapy and radiation. This review will examine the anatomy, modes of disease spread and recurrence, and evaluate the existing evidence for treatment options for these tumors. An in-depth examination of specific radiation therapy (RT) techniques-such as conventional 3D-conformal RT and intensity-modulated RT-will be discussed along with modern dose constraints. RT field arrangement, patient setup, and recommended gross and clinical target volume (CTV) contours will be considered. Areas in need of further investigation, such as the role in treatment for positron emission tomography (PET) will be explored.
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Affiliation(s)
- Eli D Scher
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Inaya Ahmed
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Ning J Yue
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Salma K Jabbour
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
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Koerber SA, Slynko A, Haefner MF, Krug D, Schoneweg C, Kessel K, Kopp-Schneider A, Herfarth K, Debus J, Sterzing F. Efficacy and toxicity of chemoradiation in patients with anal cancer--a retrospective analysis. Radiat Oncol 2014; 9:113. [PMID: 24886574 PMCID: PMC4030022 DOI: 10.1186/1748-717x-9-113] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 05/02/2014] [Indexed: 12/15/2022] Open
Abstract
Background Concurrent chemotherapy and radiation therapy is the preferred standard of care for patients with anal cancer. Several studies have suggested a benefit of intensity-modulated radiation therapy (IMRT) compared with 3D-conformal radiation (3D-CRT) regarding acute toxicity. This study evaluates outcome and toxicity of patients undergoing IMRT/Tomotherapy or 3D-CRT at our institution. Methods A cohort of 105 anal cancer patients was treated with chemoradiation or radiation alone (16.2%) between January 2000 and December 2011. 37 patients received 3D-CRT while 68 patients were treated with IMRT. Follow-up exams were performed every 3 to 6 months for a minimum of 3 years and then annually. Results Median follow-up was 41.4 months (2.8 – 158.4). Overall survival (OS), Progression-free survival (PFS) and local control (LC) at 3 years was 70.3%, 66.5%, 78.3% in the 3D-CRT group and 82.9%, 66.5%, 75.3% in the IMRT group without statistically significant difference. 3-year Colostomy-free survival (CFS) was 85.7% in the IMRT/Tomotherapy group and 91.8% in the 3D-CRT group (p = 0.48). No grade 4 toxicity was found in both groups. Severe (G2/3) acute skin toxicity (94.6% vs. 63.2%; p < 0.001) and acute gastrointestinal toxicity rate (67.6% vs. 47.1%; p = 0.03) was significantly higher with 3D-CRT compared to IMRT/Tomotherapy. Conclusion The use of IMRT can reduce acute severe side effects of the skin and gastrointestinal tract but did not demonstrate improved results regarding OS, PFS, LC and CFS.
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