1
|
Hallqvist D, Kormann C, Pigorsch S, Kiechle M, Combs SE, Habermehl D. Bone marrow toxicity in patients with locally advanced cervical cancer undergoing multimodal treatment with VMAT/IMRT: are there dosimetric predictors for toxicity? Eur J Med Res 2024; 29:445. [PMID: 39217367 PMCID: PMC11365135 DOI: 10.1186/s40001-024-02041-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024] Open
Abstract
PURPOSE For women with locoregionally advanced cervical cancer, the standard of care treatment is the curatively intended chemoradiation therapy (CRT). A relationship between bone marrow (BM) dose-volume histograms (DVHs) and acute hematological toxicity (HT) has been debated recently. Aim of this study was the evaluation of BM dose constraints and HT in a contemporary patient cohort. METHODS Radiation treatment plans of 31 patients with cervical cancer (FIGO stage IIB-IVB) treated with intensity-modulated radiotherapy and simultaneous chemotherapy were explored retrospective. Pelvic bones (PB) and femoral heads (FH) were contoured and DVHs were correlated with white blood cells (WBC), hemoglobin levels and platelets. RESULTS Comparing the absolute blood levels with the dose volumes of both FH and PB the data showed a significant correlation between WBC and the median dose of the FH and the median dose, V30Gy, V40Gy and V50Gy of the PB. A correlation between the toxicity grade of anemia and mean dose, maximum dose and V5Gy of the PB was found. Counting the highest grade of HT of all three blood levels of each patient, significant correlations were found for the mean and median dose, V30Gy, V40Gy and V50Gy of the PB. CONCLUSION The results show that blood levels may correlate with distinct dosimetric subvolumes of critical bone marrow compartments with a potential impact on therapeutic outcome and treatment-related toxicity. The data presented are in line with the previous findings on the relevance of dosimetric exposure of pelvic bony subvolumes.
Collapse
Affiliation(s)
- D Hallqvist
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - C Kormann
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - S Pigorsch
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - M Kiechle
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - S E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), HelmholtzZentrum München, Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - D Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany.
- Department of Radiation Oncology, Giessen-Marburg University Hospital, Giessen, Germany.
| |
Collapse
|
2
|
Bull C, Morén AT, Skokic V, Wilderäng U, Malipatlolla D, Alevronta E, Dunberger G, Sjöberg F, Bergmark K, Steineck G. Intra-abdominal Surgery and Intestinal Syndromes After Pelvic Radiation Therapy. Adv Radiat Oncol 2024; 9:101303. [PMID: 38260232 PMCID: PMC10801660 DOI: 10.1016/j.adro.2023.101303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/16/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose To determine the effects of intra-abdominal surgery on the intensities of 5 radiation-induced intestinal syndromes in survivors of pelvic cancer. Methods and Materials The analysis included 623 women born in 1927 or later who had survived cancer. They all had received external radiation therapy toward the pelvic area to treat gynecologic cancers. Information from 344 women who did not undergo irradiation, matched for age and residency, was also included. Main outcome measures after the surgical procedures were the intensity scores for 5 radiation-induced intestinal syndromes: urgency-tenesmus syndrome, fecal-leakage syndrome, excessive mucus discharge, excessive gas discharge, and blood discharge. The scores were based on symptom frequencies obtained from patient-reported outcomes and on factor loadings obtained from a previously reported factor analysis. Follow-up was 2 to 15 years after radiation therapy. Results Among survivors of cancer, intra-abdominal surgery increased the intensity of the urgency-tenesmus syndrome, the fecal-leakage syndrome, excessive gas discharge, and blood discharge but had a negligible effect on mucus discharge. Intra-abdominal surgery had an especially negative effect on the urgency-tenesmus syndrome. Although the combination of appendectomy with 1 or more other intra-abdominal surgeries resulted in the highest score for all syndromes, appendectomy alone had weak to no effect. In women who did not undergo irradiation, a similar pattern was seen, albeit with much lower scores. Conclusions We found intra-abdominal surgery to be a risk factor among survivors of gynecologic cancer, increasing the intensity score of 4 out of 5 radiation-induced intestinal syndromes. During radiation therapy, it may be worthwhile to pay extra attention to the dose of unwanted ionizing radiation to the intestines if the patient previously has undergone intra-abdominal surgery.
Collapse
Affiliation(s)
- Cecilia Bull
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Amelie Toft Morén
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Viktor Skokic
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
- Division of Clinical Cancer Epidemiology, Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Ulrica Wilderäng
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Dilip Malipatlolla
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Eleftheria Alevronta
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Gail Dunberger
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
| | - Fei Sjöberg
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
- Department of Infectious Diseases at the Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Karin Bergmark
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Gunnar Steineck
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| |
Collapse
|
3
|
Sha ST, Usadi B, Wang Q, Tomaino M, Brooks GA, Loehrer AP, Wong SL, Tosteson AN, Colla CH, Kapadia NS. The Association of Rural Residence With Surgery and Adjuvant Radiation in Medicare Beneficiaries With Rectal Cancer. Adv Radiat Oncol 2023; 8:101286. [PMID: 38047230 PMCID: PMC10692300 DOI: 10.1016/j.adro.2023.101286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/01/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Radiation therapy and surgery are fundamental site-directed therapies for nonmetastatic rectal cancer. To understand the relationship between rurality and access to specialized care, we characterized the association of rural patient residence with receipt of surgery and radiation therapy among Medicare beneficiaries with rectal cancer. Methods and Materials We identified fee-for-service Medicare beneficiaries aged 65 years or older diagnosed with nonmetastatic rectal cancer from 2016 to 2018. Beneficiary place of residence was assigned to one of 3 geographic categories (metropolitan, micropolitan, or small town/rural) based on census tract and corresponding rural urban commuting area codes. Multivariable regression models were used to determine associations between levels of rurality and receipt of both radiation and proctectomy within 180 days of diagnosis. In addition, we explored associations between patient rurality and characteristics of surgery and radiation such as minimally invasive surgery (MIS) or intensity modulated radiation therapy (IMRT). Results Among 13,454 Medicare beneficiaries with nonmetastatic rectal cancer, 3926 (29.2%) underwent proctectomy within 180 days of being diagnosed with rectal cancer, and 1792 (13.3%) received both radiation and proctectomy. Small town/rural residence was associated with an increased likelihood of receiving both radiation and proctectomy within 180 days of diagnosis (adjusted subhazard ratio, 1.15; 95% CI, 1.02-1.30). Furthermore, small town/rural radiation patients were significantly less likely to receive IMRT (adjusted odds ratio, 0.62; 95% CI, 0.48-0.80) or MIS (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97) than metropolitan patients. Conclusions Although small town/rural Medicare beneficiaries were overall more likely to receive both radiation and proctectomy for their rectal cancer, they were less likely to receive preoperative IMRT or MIS as part of their treatment regimen. Together, these findings clarify that among Medicare beneficiaries, there appeared to be a similar utilization of radiation resources and time to radiation treatment regardless of rural/urban status.
Collapse
Affiliation(s)
- Sybil T. Sha
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Medicine, Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Benjamin Usadi
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Qianfei Wang
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Marisa Tomaino
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Gabriel A. Brooks
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Medicine, Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Andrew P. Loehrer
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Sandra L. Wong
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anna N.A. Tosteson
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Carrie H. Colla
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Congressional Budget Office, Washington District of Columbia
| | - Nirav S. Kapadia
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Medicine, Section of Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
4
|
Hirotaki K, Tomizawa K, Moriya S, Oyoshi H, Raturi V, Ito M, Sakae T. Fully automated volumetric modulated arc therapy planning for locally advanced rectal cancer: feasibility and efficiency. Radiat Oncol 2023; 18:147. [PMID: 37670390 PMCID: PMC10481560 DOI: 10.1186/s13014-023-02334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Volumetric modulated arc therapy (VMAT) for locally advanced rectal cancer (LARC) has emerged as a promising technique, but the planning process can be time-consuming and dependent on planner expertise. We aimed to develop a fully automated VMAT planning program for LARC and evaluate its feasibility and efficiency. METHODS A total of 26 LARC patients who received VMAT treatment and the computed tomography (CT) scans were included in this study. Clinical target volumes and organs at risk were contoured by radiation oncologists. The automatic planning program, developed within the Raystation treatment planning system, used scripting capabilities and a Python environment to automate the entire planning process. The automated VMAT plan (auto-VMAT) was created by our automated planning program with the 26 CT scans used in the manual VMAT plan (manual-VMAT) and their regions of interests. Dosimetric parameters and time efficiency were compared between the auto-VMAT and the manual-VMAT created by experienced planners. All results were analyzed using the Wilcoxon signed-rank sum test. RESULTS The auto-VMAT achieved comparable coverage of the target volume while demonstrating improved dose conformity and uniformity compared with the manual-VMAT. V30 and V40 in the small bowel were significantly lower in the auto-VMAT compared with those in the manual-VMAT (p < 0.001 and < 0.001, respectively); the mean dose of the bladder was also significantly reduced in the auto-VMAT (p < 0.001). Furthermore, auto-VMAT plans were consistently generated with less variability in quality. In terms of efficiency, the auto-VMAT markedly reduced the time required for planning and expedited plan approval, with 93% of cases approved within one day. CONCLUSION We developed a fully automatic feasible VMAT plan creation program for LARC. The auto-VMAT maintained target coverage while providing organs at risk dose reduction. The developed program dramatically reduced the time to approval.
Collapse
Affiliation(s)
- Kouta Hirotaki
- Doctoral Program in Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Kento Tomizawa
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, 277-8577, Kashiwa, Chiba, Japan.
| | | | - Hajime Oyoshi
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Vijay Raturi
- Department of Radiation Oncology, Apollomedics Hospital, Lucknow, India
| | - Masashi Ito
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Takeji Sakae
- Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| |
Collapse
|
5
|
[Impact of IMRT for neoadjuvant rectal cancer?]. Cancer Radiother 2022; 26:865-870. [PMID: 36064531 DOI: 10.1016/j.canrad.2022.06.001] [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: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/22/2022]
Abstract
The standard management of locally advanced rectal tumors as cT3-T4 and/or N0/N1 is based on preoperative treatment combining radiotherapy of 45 to 50Gy and chemotherapy based on 5-fluorouracil. Intensity-modulated radiotherapy has already shown its interest compared to conformal radiotherapy in other locations, like in pelvic cancer. The role of intensity-modulated radiotherapy in the pre/postoperative treatment of rectal cancers is not a standard of care. Published studies showed its feasibility with the objective of less toxicity with equivalent efficacy.
Collapse
|
6
|
Long-Term Outcome in a Phase II Study of Regional Hyperthermia Added to Preoperative Radiochemotherapy in Locally Advanced and Recurrent Rectal Adenocarcinomas. Cancers (Basel) 2022; 14:cancers14030705. [PMID: 35158972 PMCID: PMC8833356 DOI: 10.3390/cancers14030705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 12/14/2022] Open
Abstract
Hyperthermia was added to standard preoperative chemoradiation for rectal adenocarcinomas in a phase II study. Patients with T3-4 N0-2 M0 rectal cancer or local recurrences were included. Radiation dose was 54 Gy combined with capecitabine 825 mg/m2 × 2 daily and once weekly oxaliplatin 55 mg/m2. Regional hyperthermia aimed at 41.5–42.5 °C for 60 min combined with oxaliplatin infusion. Radical surgery with total or extended TME technique, was scheduled at 6–8 weeks after radiation. From April 2003 to April 2008, a total of 49 eligible patients were recruited. Median number of hyperthermia sessions were 5.4. A total of 47 out of 49 patients (96%) had the scheduled surgery, which was clinically radical in 44 patients. Complete tumour regression occurred in 29.8% of the patients who also exhibited statistically significantly better RFS and CSS. Rate of local recurrence alone at 10 years was 9.1%, distant metastases alone occurred in 25.6%, including local recurrences 40.4%. RFS for all patients was 54.8% after 5 years and CSS was 73.5%. Patients with T50 temperatures in tumours above median 39.9 °C had better RFS, 66.7% vs. 31.3%, p = 0.047, indicating a role of hyperthermia. Toxicity was acceptable.
Collapse
|
7
|
Vendrely V, Rivin Del Campo E, Modesto A, Jolnerowski M, Meillan N, Chiavassa S, Serre AA, Gérard JP, Créhanges G, Huguet F, Lemanski C, Peiffert D. Rectal cancer radiotherapy. Cancer Radiother 2021; 26:272-278. [PMID: 34953708 DOI: 10.1016/j.canrad.2021.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We present the updated recommendations of the French society of oncological radiotherapy for rectal cancer radiotherapy. The standard treatment for locally advanced rectal cancer consists in chemoradiotherapy followed by radical surgery with total mesorectal resection and adjuvant chemotherapy according to nodal status. Although this strategy efficiently reduced local recurrences rates below 5% in expert centres, functional sequelae could not be avoided resulting in 20 to 30% morbidity rates. The early introduction of neoadjuvant chemotherapy has proven beneficial in recent trials, in terms of recurrence free and metastasis free survivals. Complete pathological responses were obtained in 15% of tumours treated by chemoradiation, even reaching up to 30% of tumours when neoadjuvant chemotherapy is associated to chemoradiotherapy. These good results question the relevance of systematic radical surgery in good responders. Personalized therapeutic strategies are now possible by improved imaging modalities with circumferential margin assessed by magnetic resonance imaging, by intensity modulated radiotherapy and by refining surgical techniques, and contribute to morbidity reduction. Keeping the same objectives, ongoing trials are now evaluating therapeutic de-escalation strategies, in particular rectal preservation for good responders after neoadjuvant treatment, or radiotherapy omission in selected cases (Greccar 12, Opera, Norad).
Collapse
Affiliation(s)
- 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.
| | - E Rivin Del Campo
- Service d'oncologie radiothérapie, hôpital Tenon, Hôpitaux universitaires Est Parisien, Sorbonne université, 75020 Paris, France
| | - A Modesto
- Service d'oncologie radiothérapie, institut Claudius-Regaud, université de Toulouse, 31000 Toulouse, France
| | - M Jolnerowski
- Service universitaire de radiothérapie, Institut de cancérologie de Lorraine centre Alexis-Vautrin, 54000 Nancy, France
| | - N Meillan
- Service d'oncologie radiothérapie, hôpital Pitié Salpêtrière, APHP, Sorbonne université, 75013 Paris, France
| | - S Chiavassa
- Service de physique médicale, Institut de cancérologie de l'Ouest (ICO) centre René-Gauducheau, 44805 Saint-Herblain, France
| | - A-A Serre
- Service d'oncologie radiothérapie, centre Léon-Bérard, 69000 Lyon, France
| | - J-P Gérard
- Service d'oncologie radiothérapie, centre Antoine-Lacassagne, université Côte d'Azur, 06000 Nice, France
| | - G Créhanges
- Service d'oncologie radiothérapie, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - F Huguet
- Service d'oncologie radiothérapie, hôpital Tenon, Hôpitaux universitaires Est Parisien, Sorbonne université, 75020 Paris, France
| | - C Lemanski
- Fédération universitaire d'oncologie radiothérapie d'Occitanie Méditerranée, Institut du cancer de Montpellier, université de Montpellier, 34000 Montpellier, France
| | - D Peiffert
- Service universitaire de radiothérapie, Institut de cancérologie de Lorraine centre Alexis-Vautrin, 54000 Nancy, France
| |
Collapse
|
8
|
Fiore M, Greco C, Coppola A, Caricato M, Caputo D, Trecca P, Floreno B, Rinaldi CG, Ippolito E, Capolupo GT, Grippo R, Beomonte Zobel B, D'Angelillo RM, Trodella L, Ramella S. Long-Term Results of a Prospective Phase 2 Study on Volume De-Escalation in Neoadjuvant Chemoradiotherapy of Rectal Cancer. Pract Radiat Oncol 2021; 11:e186-e194. [PMID: 33002647 DOI: 10.1016/j.prro.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE In the current study, we evaluated whether neoadjuvant chemoradiotherapy with reduced treatment volumes due to the exclusion of elective pelvic nodal irradiation is a feasible strategy for selected patients with locally advanced rectal cancer. METHODS AND MATERIALS Patients with T2 low-lying/T3, N0-N1 rectal lesions without evidence of disease in the lateral lymph nodes were prospectively recruited. All patients underwent pretreatment testing, including computed tomography imaging of the chest, abdomen, and pelvis with intravenous contrast, pelvic magnetic resonance imaging with intravenous contrast, and 18-fluorodeoxyglucose positron emission/computed tomography. The clinical target volume included the primary tumor and the mesorectum with vascular supply containing the perirectal and presacral nodes, with the upper border at the S2/S3 interspace. The total radiation dose was 50.4 Gy, and fluoropyrimidine-based chemotherapy was associated concomitantly. The primary endpoint of the study was the reduction of gastrointestinal (GI) toxicity, and the secondary endpoints were pathologic complete response, local control, overall survival, and disease-free survival. RESULTS Fifty-two patients (30 men, 22 women) with a median age of 67 years (range, 45-85 years) were enrolled in the study. Acute grade 3 GI toxicity was 7.6%, and there were no cases of grade 4 toxicity. Three patients (5.7%) developed a local recurrence. No relapse occurred in the lateral lymph nodes. The local control rate at 5 years was 96.1%. With a median follow-up time of 72.9 months (range, 2.5-127.6 months), the 3- and 5-year overall survival rates were 89.4% and 87%, respectively. The 3- and 5-year disease-free survival rates were 82.4% and 82.4%, respectively. CONCLUSIONS De-escalation of radiation therapy target volume reduces GI side effects without compromising efficacy in patients with rectal cancer. These results cannot be clearly extended to high-risk disease and need further evaluation in future randomized trials.
Collapse
Affiliation(s)
- Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy.
| | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | | | - Marco Caricato
- Geriatric Surgery, Campus Bio-Medico University, Rome, Italy
| | - Damiano Caputo
- General Surgery, Campus Bio-Medico University, Rome, Italy
| | - Pasquale Trecca
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Barnaba Floreno
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Carla G Rinaldi
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Edy Ippolito
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | | | - Raffaele Grippo
- Diagnostic Imaging, Campus Bio-Medico University, Rome, Italy
| | | | | | - Lucio Trodella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| |
Collapse
|
9
|
Wo JY, Anker CJ, Ashman JB, Bhadkamkar NA, Bradfield L, Chang DT, Dorth J, Garcia-Aguilar J, Goff D, Jacqmin D, Kelly P, Newman NB, Olsen J, Raldow AC, Ruiz-Garcia E, Stitzenberg KB, Thomas CR, Wu QJ, Das P. Radiation Therapy for Rectal Cancer: Executive Summary of an ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2021; 11:13-25. [PMID: 33097436 DOI: 10.1016/j.prro.2020.08.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE This guideline reviews the evidence and provides recommendations for the indications and appropriate technique and dose of neoadjuvant radiation therapy (RT) in the treatment of localized rectal cancer. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the use of RT in preoperative management of operable rectal cancer. These questions included the indications for neoadjuvant RT, identification of appropriate neoadjuvant regimens, indications for consideration of a nonoperative or local excision approach after chemoradiation, and appropriate treatment volumes and techniques. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Neoadjuvant RT is recommended for patients with stage II-III rectal cancer, with either conventional fractionation with concurrent 5-FU or capecitabine or short-course RT. RT should be performed preoperatively rather than postoperatively. Omission of preoperative RT is conditionally recommended in selected patients with lower risk of locoregional recurrence. Addition of chemotherapy before or after chemoradiation or after short-course RT is conditionally recommended. Nonoperative management is conditionally recommended if a clinical complete response is achieved after neoadjuvant treatment in selected patients. Inclusion of the rectum and mesorectal, presacral, internal iliac, and obturator nodes in the clinical treatment volume is recommended. In addition, inclusion of external iliac nodes is conditionally recommended in patients with tumors invading an anterior organ or structure, and inclusion of inguinal and external iliac nodes is conditionally recommended in patients with tumors involving the anal canal. CONCLUSIONS Based on currently published data, the American Society for Radiation Oncology task force has proposed evidence-based recommendations regarding the use of RT for rectal cancer. Future studies will look to further personalize treatment recommendations to optimize treatment outcomes and quality of life.
Collapse
Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | | | | | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jennifer Dorth
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland, Ohio
| | - Julio Garcia-Aguilar
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Goff
- Patient Representative, Las Cruces, New Mexico
| | - Dustin Jacqmin
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin
| | - Patrick Kelly
- Department of Radiation Oncology, Orlando Health, Orlando, Florida
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey Olsen
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Erika Ruiz-Garcia
- Department of Medical Oncology, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Charles R Thomas
- Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon
| | - Q Jackie Wu
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Prajnan Das
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
| |
Collapse
|