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Puri R, Rastogi M, Gandhi AK, Khurana R, Hadi R, Sapru S, Pandey A, Agarwal A, Srivastava AK, Mishra SP, Khatoon F, Bharati A, Mishra VK, Manral A, Mishra P. Prospective evaluation of dose-escalated preoperative concurrent chemo-radiation with image guided-IMRT in locally advanced rectal cancers. Ecancermedicalscience 2023; 17:1583. [PMID: 37533948 PMCID: PMC10393306 DOI: 10.3332/ecancer.2023.1583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 08/04/2023] Open
Abstract
Purpose To analyse the safety and efficacy of neoadjuvant chemoradiation (NACRT) with dose-escalated image-guided intensity modulated radiation therapy (IG-IMRT) in locally advanced (T3/4; T1-4N1-2) rectal cancers (LARCs). Materials and methods Twenty patients with the diagnosis of LARC were recruited in this prospective interventional single-arm study treated by IG-IMRT with 45 Gray (Gy) in 25 fractions to elective nodal volumes and 55 Gy in 25 fractions to the gross primary and nodal disease with concurrent capecitabine 825 mg/m2 twice daily on radiotherapy days. Patients underwent total mesorectal excision 6-8 weeks post completion of NACRT followed by adjuvant chemotherapy (Capecitabine and oxaliplatin every 3 weekly for 6-8 cycles). Primary end point was acute toxicity assessment and secondary end points were pathological complete response (pCR) and loco-regional control (LRC). Results Clinical T stage was T3:T4 in 19:1 and clinical N0:N1: N2 in 2:7:11 patients, respectively. With a median follow up of 21.2 months (13.8-25.6 months), 18 of 20 (90%) patients received the full course of treatment. Tumour and nodal downstaging was achieved in 78% and 84% of patients, respectively. pCR and overall complete response (defined as pCR and near CR) was achieved in 22.2% and 44.4% of patients, respectively. 2 (10%) patients completed NACRT, and achieved complete clinical response but refused surgery. Adjuvant chemotherapy course was completed by 17/18 (94.5%) patients. Grade 3 toxicities were observed in 2 (10%) patients during NACRT. All patients were disease-free at the time of the last follow up. Conclusion Dose-escalation of NACRT therapy with IG-IMRT in LARC patients offers decent rates of pCR and overall response with excellent LRC and acceptable toxicities.
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Affiliation(s)
- Raunaq Puri
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Madhup Rastogi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Ajeet Kumar Gandhi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Rohini Khurana
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Rahat Hadi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Shantanu Sapru
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Anshuman Pandey
- Department of Surgical Gastroenterology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Akash Agarwal
- Department of Surgical Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Anoop Kumar Srivastava
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Surendra Prasad Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Farhana Khatoon
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Avinav Bharati
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Vachaspati Kumar Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Akanksha Manral
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Prasoon Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
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[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.
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Simultaneous Integrated Boost Volumetric Modulated Arc Therapy for Rectal Cancer: Long-Term Results after Protocol-Based Treatment. JOURNAL OF ONCOLOGY 2022; 2022:6986267. [PMID: 35437441 PMCID: PMC9012974 DOI: 10.1155/2022/6986267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
Background Volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) is an advanced form of radiotherapy (RT) technology. The purpose of this study was to report long-term treatment outcomes in patients with locally advanced rectal cancer undergoing VMAT-SIB based concurrent chemoradiotherapy (CRT). Methods Between January 2016 and January 2018, a total of 22 patients with operable stage II-III rectal adenocarcinoma were recruited for the pre-designed VMAT-SIB RT protocol. All patients underwent standard diagnostic and staging work-up. The RT target volumes included the following areas: PTV1 = mesorectum that contained gross tumors and enlarged lymph node regions and PTV2 = mesorectum and regional lymphatics from L4-5/S1 to 3-4 cm below the tumor or levator ani muscle, excluding PTV1. The VMAT-SIB dose prescription was as follows: PTV1 = 52.5 Gy/daily 2.1 Gy/25 fractions, PTV2 = 45 Gy/daily 1.8 Gy/25 fractions. Results The mean age of the study population was 64 (range, 18-84) years, and 15 (68.2%) patients were male. Radical operation (total mesorectal excision) was performed by either low anterior resection, ultralow anterior resection, or abdominal perineal resection. All five (22.7%) of the patients with confirmed increasing serum carcinoembryonic antigen (CEA) level at diagnosis showed normalization of serum CEA level after the planned treatment. Among 20 patients who underwent preoperative CRT and surgery, tumor down staging in T- and N-stages was achieved in 10 patients (50%) and 13 patients (65%), respectively, with 20% of ypT0/Tis. With a median follow-up of 54.2 (range, 22.6-61.1) months, the 5-year disease-free survival, overall survival, and local control rates were 64.6%, 81.8%, and 84.4%, respectively. Five patients developed distant metastasis and one developed local recurrence as a first event. Two cases with anastomosis site leakage, three with adhesive ileus, and two with abscess formation were observed during postoperative periods. Conclusions The current VMAT-SIB-based CRT protocol provided acceptable treatment and toxicity outcomes.
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Preoperative intensity-modulated chemoradiotherapy with simultaneous integrated boost in rectal cancer: five-year follow-up results of a phase II study. Radiol Oncol 2021; 55:439-448. [PMID: 34821132 PMCID: PMC8647794 DOI: 10.2478/raon-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background We conducted a phase II study to investigate the feasibility and safety of preoperative radiochemo-therapy experimental fractionation, using intensity-modulated radiation therapy with simultaneous integrated boost (IMRT SIB) to shorten the overall treatment time without dose escalation in intermediate/locally advanced rectal cancer with the aim to improving treatment outcome. Patients and methods A total of 51 patients with operable stage II–III rectal carcinoma were included between January 2014 and January 2015. Fifty patients completed preoperative IMRT treatment with an elective dose of 41.8 Gy and simultaneously delivered 46.2 Gy to T2/T3 and 48.4 Gy to T4 tumour in 22 fractions, with concomitant capecitabine (825 mg/m2/12 h, including at weekends). Median follow-up was 70 months (range 11–80 m). Results Forty-seven patients completed treatment per protocol. Acute toxicity occurred in 2 (4%) patients. R0 resection was achieved in all but 1 and pathologic complete response (pCR) in 12 (25.5%) patients who had 5-year overall survival (OS), disease-free survival (DFS) and local control (LC) of 91.7%, 100% and 100%, respectively. The intention-to-treat analysis showed that the type of surgery significantly moderated OS and DFS, while total downstaging and pN were predictive for DFS only. For treatment per protocol 5-year OS, DFS and LC were 80.9% (95% confidence interval [CI] 69.7–92.1), 77.1% (95% CI 65.1–89.1) and 95.2% (95% CI 88.7–100), respectively. The proportion of patients with severe late (CTCAE G ≥ 3) gastrointestinal, urinary and sexual toxicity was 15%, 2% and 8% respectively, with one reported secondary carcinoma. Conclusions Preoperative IMRT-SIB without dose escalation was well tolerated, with a low acute toxicity profile, we achieved a high rate of pCR and showed encouraging 5-year OS, DFS and LC.
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Delishaj D, Fumagalli IC, Ursino S, Cristaudo A, Colangelo F, Stefanelli A, Alghisi A, De Nobili G, D’Amico R, Cocchi A, Ardizzoia A, Soatti CP. Neoadjuvant radiotherapy dose escalation for locally advanced rectal cancers in the new era of radiotherapy: A review of literature. World J Clin Cases 2021; 9:9077-9089. [PMID: 34786390 PMCID: PMC8567526 DOI: 10.12998/wjcc.v9.i30.9077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/27/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The standard treatment of locally advanced rectal cancers (LARC) consists on neoadjuvant chemoradiotherapy followed by total mesorectal excision. Different data in literature showed a benefit on tumor downstaging and pathological complete response (pCR) rate using radiotherapy dose escalation, however there is shortage of studies regarding dose escalation using the innovative techniques for LARC (T3-4 or N1-2).
AIM To analyze the role of neoadjuvant radiotherapy dose escalation for LARC using innovative radiotherapy techniques.
METHODS In December 2020, we conducted a comprehensive literature search of the following electronic databases: PubMed, Web of Science, Scopus and Cochrane library. The limit period of research included articles published from January 2009 to December 2020. Screening by title and abstract was carried out to identify only studies using radiation doses equivalent dose 2 Gy fraction (EQD2) ≥ 54 Gy and Volumetric Modulated Arc Therapy (VMAT), intensity-modulated radiotherapy or image-guided radiotherapy (IGRT) techniques. The authors’ searches generated a total of 2287 results and, according to PRISMA Group (2009) screening process, 21 publications fulfil selection criteria and were included for the review.
RESULTS The main radiotherapy technique used consisted in VMAT and IGRT modality. The mainly dose prescription was 55 Gy to high risk volume and 45 Gy as prophylactic volume in 25 fractions given with simultaneous integrated boosts technique (42.85%). The mean pCR was 28.2% with no correlation between dose prescribed and response rates (P value ≥ 0.5). The R0 margins and sphincter preservation rates were 98.88% and 76.03%, respectively. After a mean follow-up of 35 months local control was 92.29%. G3 or higher toxicity was 11.06% with no correlation between dose prescription and toxicities. Patients receiving EQD2 dose > 58.9 Gy and BED > 70.7 Gy had higher surgical complications rates compared to other group (P value = 0.047).
CONCLUSION Dose escalation neoadjuvant radiotherapy using innovative techniques is safe for LARC achieving higher rates of pCR. EQD2 doses > 58.9 Gy is associated with higher rate of surgical complications.
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Affiliation(s)
- Durim Delishaj
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | | | - Stefano Ursino
- Department of Radiation Oncology, Santa Chiara University Hospital, Pisa 56126, Italy
| | - Agostino Cristaudo
- Royal Preston Hospital, Lancashire Teaching Hospital- NHS Tust, Preston PR2 9HT, United Kingdom
| | - Francesco Colangelo
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Antonio Stefanelli
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara 44124, Italy
| | - Alessandro Alghisi
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Giuseppe De Nobili
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Romerai D’Amico
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Alessandra Cocchi
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Antonio Ardizzoia
- Department of Clinical Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Carlo Pietro Soatti
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
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Hanna CR, Slevin F, Appelt A, Beavon M, Adams R, Arthur C, Beasley M, Duffton A, Gilbert A, Gollins S, Harrison M, Hawkins MA, Laws K, O'Cathail S, Porcu P, Robinson M, Sebag-Montefiore D, Teo M, Teoh S, Muirhead R. Intensity-modulated Radiotherapy for Rectal Cancer in the UK in 2020. Clin Oncol (R Coll Radiol) 2021; 33:214-223. [PMID: 33423883 PMCID: PMC7985673 DOI: 10.1016/j.clon.2020.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/13/2020] [Accepted: 12/11/2020] [Indexed: 12/15/2022]
Abstract
AIMS Preoperative (chemo)radiotherapy followed by total mesorectal excision is the current standard of care for patients with locally advanced rectal cancer. The use of intensity-modulated radiotherapy (IMRT) for rectal cancer is increasing in the UK. However, the extent of IMRT implementation and current practice was not previously known. A national survey was commissioned to investigate the landscape of IMRT use for rectal cancer and to inform the development of national rectal cancer IMRT guidance. MATERIALS AND METHODS A web-based survey was developed by the National Rectal Cancer IMRT Guidance working group in collaboration with the Royal College of Radiologists and disseminated to all UK radiotherapy centres. The survey enquired about the implementation of IMRT with a focus on the following aspects of the workflow: dose fractionation schedules and use of a boost; pre-treatment preparation and simulation; target volume/organ at risk definition; treatment planning and treatment verification. A descriptive statistical analysis was carried out. RESULTS In total, 44 of 63 centres (70%) responded to the survey; 30/44 (68%) and 36/44 (82%) centres currently use IMRT to treat all patients and selected patients with rectal cancer, respectively. There was general agreement concerning several aspects of the IMRT workflow, including patient positioning, use of intravenous contrast and bladder protocols. Greater variation in practice was identified regarding rectal protocols; use of a boost to primary/nodal disease; target volume delineation; organ at risk delineation and dose constraints and treatment verification. Delineation of individual small bowel loops and daily volumetric treatment verification were considered potentially feasible by most centres. CONCLUSION This survey identified that IMRT is already used to treat rectal cancer in many UK radiotherapy centres, but there is heterogeneity between centres in its implementation and practice. These results have been a valuable aid in framing the recommendations within the new National Rectal Cancer IMRT Guidance.
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Affiliation(s)
- C R Hanna
- CRUK Clinical Trials Unit, University of Glasgow, Glasgow, UK; Beatson West of Scotland Cancer Centre, Glasgow, UK.
| | - F Slevin
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Appelt
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M Beavon
- Royal College of Radiologists, London, UK
| | - R Adams
- Velindre Cancer Centre, Cardiff, UK
| | - C Arthur
- The Christie NHS Foundation Trust, Manchester, UK
| | - M Beasley
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Duffton
- CRUK Clinical Trials Unit, University of Glasgow, Glasgow, UK; Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - A Gilbert
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S Gollins
- North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Rhyl, UK
| | - M Harrison
- Mount Vernon Cancer Centre, Northwood, UK
| | - M A Hawkins
- Medical Physics and Biochemical Engineering, University College London, London, UK
| | - K Laws
- Aberdeen Cancer Centre, Aberdeen Royal Infirmary, Aberdeen, UK
| | - S O'Cathail
- CRUK Clinical Trials Unit, University of Glasgow, Glasgow, UK; Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - P Porcu
- Royal Free London NHS Foundation Trust, London, UK
| | - M Robinson
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D Sebag-Montefiore
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M Teo
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S Teoh
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Muirhead
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Roeder F, Meldolesi E, Gerum S, Valentini V, Rödel C. Recent advances in (chemo-)radiation therapy for rectal cancer: a comprehensive review. Radiat Oncol 2020; 15:262. [PMID: 33172475 PMCID: PMC7656724 DOI: 10.1186/s13014-020-01695-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022] Open
Abstract
The role of radiation therapy in the treatment of (colo)-rectal cancer has changed dramatically over the past decades. Introduced with the aim of reducing the high rates of local recurrences after conventional surgery, major developments in imaging, surgical technique, systemic therapy and radiation delivery have now created a much more complex environment leading to a more personalized approach. Functional aspects including reduction of acute or late treatment-related side effects, sphincter or even organ-preservation and the unsolved problem of still high distant failure rates have become more important while local recurrence rates can be kept low in the vast majority of patients. This review summarizes the actual role of radiation therapy in different subgroups of patients with rectal cancer, including the current standard approach in different subgroups as well as recent developments focusing on neoadjuvant treatment intensification and/or non-operative treatment approaches aiming at organ-preservation.
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Affiliation(s)
- F Roeder
- Department of Radiotherapy and Radiation Oncology, Paracelsus Medical University, Landeskrankenhaus, Müllner Hautpstrasse 48, 5020, Salzburg, Austria.
| | - E Meldolesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - S Gerum
- Department of Radiotherapy and Radiation Oncology, Paracelsus Medical University, Landeskrankenhaus, Müllner Hautpstrasse 48, 5020, Salzburg, Austria
| | - V Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - C Rödel
- Department of Radiotherapy, University of Frankfurt, Frankfurt, Germany
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Randrian V, Biau J, Benoît C, Pezet D, Lapeyre M, Moreau J. [Preoperative intensity-modulated radiotherapy of rectal cancers: Relevance and modalities]. Cancer Radiother 2020; 24:345-353. [PMID: 32360094 DOI: 10.1016/j.canrad.2019.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/27/2019] [Accepted: 11/06/2019] [Indexed: 12/18/2022]
Abstract
Preoperative radiotherapy boosted by chemotherapy is a recommended treatment in locally advanced rectal cancers. This treatment is delivered by three dimensional conformal irradiation, which is usually well tolerated but can induce potential toxicity such as rectitis, cystitis and hematologic adverse effects. Intensity-modulated radiotherapy, widely available nowadays, allows optimization of volume covering and sparing of organs at risk such as bladder and bone marrow. This review presents relevant clinical situations and requirements for a beneficial and safe preoperative irradiation of rectal cancers by intensity-modulated technique. This technique is compared to three-dimensional conformal radiotherapy.
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Affiliation(s)
- V Randrian
- Département de médecine digestive et hépatobiliaire, CHU de l'hôpital Estaing, 63003 Clermont-Ferrand cedex 1, France
| | - J Biau
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 5026, 63011 Clermont-Ferrand cedex 1, France
| | - C Benoît
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 5026, 63011 Clermont-Ferrand cedex 1, France
| | - D Pezet
- Département de chirurgie digestive et hépatobiliaire, CHU de l'hôpital Estaing, 63003 Clermont-Ferrand cedex 1, France
| | - M Lapeyre
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 5026, 63011 Clermont-Ferrand cedex 1, France
| | - J Moreau
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 5026, 63011 Clermont-Ferrand cedex 1, France.
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Ren X, Chen B, Hong Y, Liu W, Jiang Q, Yang J, Qian Q, Jiang C. The challenges in colorectal cancer management during COVID-19 epidemic. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:498. [PMID: 32395542 PMCID: PMC7210180 DOI: 10.21037/atm.2020.03.158] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
It has been over 2 months since the start of the Coronavirus disease 2019 (COVID-19) outbreak. The epidemic stage of COVID-19 has brought great challenges to the diagnosis and management of colorectal cancer (CRC) patients. Symptoms, such as fever and cough caused by cancer, and the therapeutic process (including chemotherapy and surgery) should be differentiated from some COVID-19 related characteristics. Besides, clinical workers should not only consider the therapeutic strategy for cancer, but also emphasize COVID-19's prevention. Moreover, the detailed therapeutic regimens of CRC patients may be different from the usual. Also, treatment principles may various for CRC patients with or without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, as well as patients with or without an emergency presentation. In this paper, we want to discuss the above-mentioned problems based on previous guidelines, the current working status and our experiences, to provide a reference for medical personnel.
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Affiliation(s)
- Xianghai Ren
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan 430071, China
- Hubei Key Laboratory of Intestinal and Colorectal Diseases (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Colorectal and Anal Disease Research Center of Medical School (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei Province, Wuhan 430071, China
| | - Baoxiang Chen
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan 430071, China
- Hubei Key Laboratory of Intestinal and Colorectal Diseases (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Colorectal and Anal Disease Research Center of Medical School (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei Province, Wuhan 430071, China
| | - Yuntian Hong
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan 430071, China
- Hubei Key Laboratory of Intestinal and Colorectal Diseases (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Colorectal and Anal Disease Research Center of Medical School (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei Province, Wuhan 430071, China
| | - Weicheng Liu
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan 430071, China
- Hubei Key Laboratory of Intestinal and Colorectal Diseases (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Colorectal and Anal Disease Research Center of Medical School (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei Province, Wuhan 430071, China
| | - Qi Jiang
- Department of Pathology and Pathophysiology, Hubei Provincial Key Laboratory of Developmentally Originated Disease, School of Basic Medical Sciences, Wuhan University, Wuhan 430071, China
| | - Jingying Yang
- Department of Anesthesia Surgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan 430071, China
| | - Qun Qian
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan 430071, China
- Hubei Key Laboratory of Intestinal and Colorectal Diseases (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Colorectal and Anal Disease Research Center of Medical School (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei Province, Wuhan 430071, China
| | - Congqing Jiang
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan 430071, China
- Hubei Key Laboratory of Intestinal and Colorectal Diseases (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Colorectal and Anal Disease Research Center of Medical School (Zhongnan Hospital of Wuhan University), Wuhan 430071, China
- Quality Control Center of Colorectal and Anal Surgery of Health Commission of Hubei Province, Wuhan 430071, China
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Jin F, Luo H, Zhou J, Wu Y, Sun H, Liu H, Zheng X, Wang Y. Dose-time fractionation schedules of preoperative radiotherapy and timing to surgery for rectal cancer. Ther Adv Med Oncol 2020; 12:1758835920907537. [PMID: 32165928 PMCID: PMC7052459 DOI: 10.1177/1758835920907537] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/20/2020] [Indexed: 02/01/2023] Open
Abstract
Chemoradiotherapy (CRT) is extensively used prior to surgery for rectal cancer to provide significantly better local control, but the radiotherapy (RT), as the other component of CRT, has been subject to less interest than the drug component in recent years. With considerable developments in RT, the use of advanced techniques, such as intensity-modulated radiotherapy (IMRT) in rectal cancer, is garnering more attention nowadays. The radiation dose can be better conformed to the target volumes with possibilities for synchronous integrated boost without increased complications in normal tissue. Hopefully, both local recurrence and toxicities can be further reduced. Although those seem to be of interest, many issues remain unresolved. There is no international consensus regarding the radiation schedule for preoperative RT for rectal cancer. Moreover, an enormous disparity exists regarding the RT delivery. With the advent of IMRT, variations will likely increase. Moreover, time to surgery is also quite variable, as it depends upon the indication for RT/CRT in the clinical practices. In this review, we discuss the options and problems related to both the dose-time fractionation schedule and time to surgery; furthermore, it addresses the research questions that need answering in the future.
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Affiliation(s)
- Fu Jin
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Huanli Luo
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Juan Zhou
- Forensic Identification Center, Southwest
University of Political Science and Law, Chongqing, PR China
| | - Yongzhong Wu
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Hao Sun
- Department of Gynecologic Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Hongliang Liu
- Department of Anesthesiology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Xiaodong Zheng
- Department of Science Education, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Ying Wang
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, 181 Hanyu Road, Shapingba District, Chongqing 400030,
China
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Govil D, Dhankhar D, Gupta R, Kumar S. Gastrointestinal cancer surgery during COVID times. APOLLO MEDICINE 2020. [DOI: 10.4103/am.am_79_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Abstract
Radiotherapy (RT) has remained an important pillar in the multi-modality management of rectal cancer. Adjuvant RT with concurrent chemotherapy (chemo-RT) was once the standard of care for locally advanced rectal cancer, but with time, that has now changed and neoadjuvant chemo-RT followed by total mesorectal excision (TME) surgery is the new standard. Alternatively, neoadjuvant RT alone remains an option and clinicians are tasked to choose between the two. In an era of personalised oncological management, it is unsurprising that the treatment for rectal cancer is following suit and upcoming trials are studying ways to improve outcomes and minimise toxicity for patients while tailoring treatments specific to each patient's tumour. We review the evolution of the role of RT in rectal cancer and look forward to what the future holds.
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Affiliation(s)
- Michelle Tseng
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Jeremy Tey
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
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13
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Zhao J, Liu X, Wang W, Hu K, Zhang F, Hou X, Meng Q. Concomitant dose escalation with image-guided Tomotherapy in locally advanced mid-low rectal cancer: a single-center study. Cancer Manag Res 2019; 11:1579-1586. [PMID: 30863168 PMCID: PMC6388983 DOI: 10.2147/cmar.s193657] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the efficacy and toxicity of concomitant dose-escalated Tomotherapy in locally advanced mid–low rectal cancer. Patients and methods Patients with locally advanced (T3/T4 or N+), low–mid (≤10 cm from anal verge) rectal carcinoma treated with neoadjuvant chemoradiotherapy followed by surgery between May 2012 and October 2017 in Peking Union Medical College Hospital were included in this study. A dose of 45/50 Gy in 25 fractions was delivered to the pelvis with Tomotherapy, and 55 Gy was prescribed for the primary tumor with a simultaneous, integrated boost. Megavolt computed tomography was performed before every delivery. The concurrent chemotherapy regimen included capecitabine alone and XELOX. Results A total of 141 patients were enrolled; 129 patients (91.5%) had stage cT3 or cT4, and 121 patients (85.8%) had positive lymph nodes. The location of the tumors was in the lower rectum in 88 patients (62.4%). After neoadjuvant chemoradiotherapy, 113 patients (80.1%) underwent sphincter-preserving resection. Downstaging was observed in 121 patients (85.8%), including 80 patients (56.7%) with T downstaging and 101 patients (83.5%) with N downstaging. Thirty-two patients (22.7%) obtained pathological complete response (pCR). The median follow-up was 38.5 months (range, 9.3–73.6 months). Only 36 patients (25.5%) experienced treatment failure, including distant metastasis in 29 patients (20.6%) and pelvic recurrent in 7 patients (5.0%). The estimated 5-year overall survival (OS), disease-free survival (DFS), and local control (LC) rates of patients were 75.1%, 70.9%, and 95.5%, respectively. pCR was an independent prognostic factor for DFS (HR 0.13, 95% CI: 0.02–0.93, P = 0.043), but it did not improve OS or LC. Grade 3 or greater acute leukopenia and diarrhea rates were 5.7% and 7.8%, respectively, and 15 patients (10.6%) developed postoperative complications. Conclusion This study indicates that neoadjuvant, image-guided Tomotherapy with 55 Gy boosted to the primary tumor was well tolerated and resulted in high rates of sphincter-preserving surgery, pCR, LC, and DFS for locally advanced rectal cancer.
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Affiliation(s)
- Jing Zhao
- Department of Oncology, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China, ;
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China, ;
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China, ;
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China, ;
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China, ;
| | - Qingyu Meng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China, ;
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Masson I, Delpon G, Vendrely V. [Image-guided radiotherapy contribution and patient setup for anorectal cancer treatment]. Cancer Radiother 2018; 22:622-630. [PMID: 30143462 DOI: 10.1016/j.canrad.2018.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 06/27/2018] [Indexed: 01/24/2023]
Abstract
Intensity-modulated radiation therapy is recommended in anal squamous cell carcinoma treatment and is increasingly used in rectal cancer. It adapts the dose to target volumes, with a high doses gradient. Intensity-modulated radiation therapy allows to reduce toxicity to critical normal structures and to consider dose-escalation studies or systemic treatment intensification. Image-guided radiation therapy is a warrant of quality for intensity-modulated radiation therapy, especially for successful delivery of the dose as planned. There is no recommended international or national anorectal cancer image-guided radiation therapy protocol currently available. Dose-escalation trials or expert opinions about intensity-modulated/image-guided radiation therapy good practice guidelines recommend daily volumetric imaging throughout the treatment or during the five first fractions and weekly thereafter as a minimum. Image-guided radiation therapy allows to reduce margins related to patient setup errors. Internal margin, related to the internal organ motion, needs to be adapted according to short- or long-course radiotherapy, gender, rectal location; it can be higher than current recommended planning target volume margins, particularly in the upper and anterior part of mesorectum, which has the most significant movement. Image-guided radiation therapy based on volumetric imaging allows to take target volume shrinkage into account and to develop adaptive strategies, in particular for mesorectum shrinkage during rectal cancer treatment. Lastly, the emergence of new image-guided radiation therapy technologies including MRI (which plays a major role in pelvic tumours assessment and diagnosis) opens up interesting perspectives for adaptive radiotherapy, taking into account both organs' movements and tumour shrinkage.
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Affiliation(s)
- I Masson
- Département de radiothérapie, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Jacques-Monod, 44805 Saint-Herblain, France.
| | - G Delpon
- Département de physique médicale, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - V Vendrely
- Service de radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
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