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ESTRO/ACROP IORT recommendations for intraoperative radiation therapy in primary locally advanced rectal cancer. Clin Transl Radiat Oncol 2020; 25:29-36. [PMID: 33005755 PMCID: PMC7519207 DOI: 10.1016/j.ctro.2020.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/06/2020] [Indexed: 01/13/2023] Open
Abstract
Carcinoma of the rectum is a heterogeneous disease. The clinical spectrum identifies a subset of patients with locally advanced tumours that are close to or involve adjoining structures, such as the sacrum, pelvic sidewalls, prostate or bladder. Within this group of patients categorized as "locally advanced", there is also variability in the extent of disease with no uniform definition of resectability. A practice-oriented definition of a locally advanced tumour is a tumour that cannot be resected without leaving microscopic or gross residual disease at the resection site. Since these patients do poorly with surgery alone, irradiation and chemotherapy have been added to improve the outcome. Intraoperative irradiation (IORT) is a component of local treatment intensification with favourable results in this subgroup of patients. International guidelines (National Comprehensive Cancer Network (NCCN) guidelines) currently recommend the use of IORT for rectal cancer resectable with very close or positive margins, especially for T4 and recurrent cancers. We report the ESTRO-ACROP (European Society for Radiotherapy and Oncology - Advisory Committee on Radiation Oncology Practice) recommendations for performing IORT in primary locally advanced rectal cancer.
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Hoffmann M, Waller K, Last A, Westhuyzen J. A critical literature review on the use of bellyboard devices to control small bowel dose for pelvic radiotherapy. Rep Pract Oncol Radiother 2020; 25:598-605. [PMID: 32518531 DOI: 10.1016/j.rpor.2020.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 04/10/2020] [Accepted: 04/23/2020] [Indexed: 11/16/2022] Open
Abstract
Delivering curative radiotherapy doses for rectal and gynaecological tumours has historically been complicated by the dose tolerance of the small bowel. Acute radiation-induced small bowel toxicity includes side effects such as abdominal pain, nausea and diarrhoea. With the advent of new treatment delivery modalities, such as IMRT (Intensity modulated radiotherapy) and VMAT (Volumetric modulated Arc radiotherapy), there has been an expectation that small bowel doses can be better controlled with the use of these technologies. These capabilities enable the creation of treatment plans that can better avoid critical radiosensitive organs. The purpose of this review is to look beyond advances in linear accelerator technology in seeking improvements to small bowel dose and toxicity. This review examines whether an alternative prone patient positioning approach using a bellyboard device in conjunction with IMRT and VMAT treatment delivery can reduce small bowel doses further than using these technologies with the patient in a traditional supine position.
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Affiliation(s)
- Matthew Hoffmann
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Kim Waller
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Andrew Last
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
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Bermúdez Luna R, de Torres Olombrada MV. mARC preoperative rectal cancer treatments vs. 3D conformal radiotherapy. A dose distribution comparative study. PLoS One 2019; 14:e0221262. [PMID: 31419263 PMCID: PMC6697352 DOI: 10.1371/journal.pone.0221262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 08/04/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose mARC (modulated arc) is the arc therapy technique provided by Siemens. The present study analyses the dose distributions and treatment times corresponding to preoperative rectal cancer mARC treatments. The results are compared to those corresponding to 3D-CRT plans. Methods The plans of 30 patients, each having one mARC and one 3D-CRT plan, were evaluated. Every plan was calculated on a sequential two-phase treatment scheme with prescription doses of 45 Gy in the initial phase and 5.4 Gy in the boost phase. Dosimetric parameters and mean DVHs corresponding to the PTVs and OARs were assessed for both techniques. Results All mARC plans were considered valid for treatment and yielded a highly significant improvement in the CI over 3D-CRT plans (p <0.001). They also showed statistically significant advantage on the parameters D98%, D95% and D2% of the high dose PTV. Regarding the OARs, mARC plans showed reductions in the mean dose of 3.5 Gy in the bladder and greater than 4 Gy in the femoral heads. Considering the small bowel, the mARC plans resulted in a 2.7 Gy mean reduction in the mean dose and lower irradiated volumes over the entire dose range. Conclusions Arc therapy plans with the mARC technique for preoperative rectal cancer treatment in a sequential two-phase treatment scheme provide important advantages in the PTVs and OARs. mARC plans show superior protection of the femoral heads, bladder and small bowel, similar to the results found with other more widespread arc therapy techniques.
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Affiliation(s)
- Rocío Bermúdez Luna
- Medical Physics Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
- * E-mail:
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Kim A, Karotki A, Presutti J, Gonzales G, Wong S, Chu W. The effect of prone and supine treatment positions for the pre-operative treatment of rectal cancer on organ-at-risk sparing and setup reproducibility using volumetric modulated arc therapy. Radiat Oncol 2017; 12:180. [PMID: 29202879 PMCID: PMC5715653 DOI: 10.1186/s13014-017-0918-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/04/2017] [Indexed: 02/02/2023] Open
Abstract
Background and purpose To compare organ-at-risk doses and setup reproducibility using the prone and supine orientations in volumetric modulated arc therapy (VMAT) for rectal cancer. Materials and methods Seventeen consecutive rectal cancer patients undergoing preoperative radiation were selected and setup in either the prone (N = 8) or supine (N = 9) position. All patients were treated using posteriorly-applied VMAT. Bladder and small bowel dose and cone beam CT (CBCT) reproducibility metrics were retrospectively collected. Results Dose metrics for bladder and small bowel did not show significant differences between the prone and supine orientations. The prone data had a trend for smaller irradiated volumes than supine for the small bowel at lower doses—V20 (prone: 135 ± 99 cm3; supine: 201 ± 162 cm3) and V30 (prone: 78 ± 71 cm3; supine: 105 ± 106 cm3). At higher doses, the trend reversed as exemplified by the small bowel V50.4 (prone: 20 ± 28 cm3; supine: 10 ± 14 cm3). CBCT data showed that rotational errors in pitch and roll were significantly larger for the prone vs. supine orientation (pitch: 2.0° ± 1.3° vs. 0.8° ± 1.1° p < 0.001; roll: 1.0° ± 0.9° vs. 0.3° ± 0.5°, p < 0.001). Conclusions Bladder and small bowel doses were not significantly different when comparing VMAT plans developed for the prone and supine orientations. The supine orientation demonstrated improved setup reproducibility.
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Affiliation(s)
- Anthony Kim
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Aliaksandr Karotki
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Joe Presutti
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Glen Gonzales
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Shun Wong
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - William Chu
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
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Grau C, Høyer M, Poulsen PR, Muren LP, Korreman SS, Tanderup K, Lindegaard JC, Alsner J, Overgaard J. Rethink radiotherapy - BIGART 2017. Acta Oncol 2017; 56:1341-1352. [PMID: 29148908 DOI: 10.1080/0284186x.2017.1371326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Stuyck C, Wegge M, Bulens P, Joye I, Haustermans K. Moderate dose escalation with volumetric modulated arc therapy improves outcome in rectal cancer. Acta Oncol 2017; 56:1501-1506. [PMID: 28826304 DOI: 10.1080/0284186x.2017.1350286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Locally advanced rectal cancer is frequently treated with a long course of preoperative chemoradiotherapy. We investigated the effect of moderate dose escalation with volumetric modulated arc therapy (VMAT) up to 50 Gy in 25 fractions compared to 3D conformal radiotherapy (3D-CRT) to 45 Gy in 25 fractions in rectal cancer patients. Dose-volume parameters, acute toxicity, and complete response rates were compared. MATERIAL AND METHODS For both groups, 65 patients were selected from our database through availability. Dose-volume parameters and acute toxicity data were compared using a Mann-Whitney U-test. Univariate and multivariate analyses correcting for tumor and nodal stage, distance to the mesorectal fascia and interval to surgery were used to compare complete response rates. RESULTS Lower mean doses to the small and large bowel were observed in the VMAT group compared to the 3D-CRT group (21 Gy vs. 29 Gy [p < .001] and 26 Gy vs. 30 Gy [p = .002], respectively). Similar beneficial dose-volume parameters were observed for the bladder, sacrum and femoral heads. Furthermore, patients receiving VMAT experienced significantly less diarrhea, flatulence, non-infective cystitis, urinary frequency, dermatitis, and fatigue. In univariate analysis, a significant increase in complete response rate after moderate dose escalation with VMAT was observed (34% vs. 15%, p = .015). However, this did not remain significant when corrected for tumor and nodal stage, distance to the mesorectal fascia, and interval to surgery. CONCLUSIONS Moderate dose escalation with VMAT resulted in superior dose-volume parameters compared to 3D-CRT, translating into lower acute toxicity. Additionally, improved tumor response after VMAT up to 50 Gy might contribute to a higher percentage of patients achieving a complete response.
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Affiliation(s)
- Cedric Stuyck
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Marilyn Wegge
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Philippe Bulens
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Ines Joye
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
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Glimelius B. On a prolonged interval between rectal cancer (chemo)radiotherapy and surgery. Ups J Med Sci 2017; 122:1-10. [PMID: 28256956 PMCID: PMC5361426 DOI: 10.1080/03009734.2016.1274806] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/08/2016] [Accepted: 12/16/2016] [Indexed: 12/25/2022] Open
Abstract
Preoperative radiotherapy (RT) or chemoradiotherapy (CRT) is often required before rectal cancer surgery to obtain low local recurrence rates or, in locally advanced tumours, to radically remove the tumour. RT/CRT in tumours responding completely can allow an organ-preserving strategy. The time from the end of the RT/CRT to surgery or to the decision not to operate has been prolonged during recent years. After a brief review of the literature, the relevance of the time interval to surgery is discussed depending upon the indication for RT/CRT. In intermediate rectal cancers, where the aim is to decrease local recurrence rates without any need for down-sizing/-staging, short-course RT with immediate surgery is appropriate. In elderly patients at risk for surgical complications, surgery could be delayed 5-8 weeks. If CRT is used, surgery should be performed when the acute radiation reaction has subsided or after 5-6 weeks. In locally advanced tumours, where CRT is indicated, the optimal delay is 6-8 weeks. In patients not tolerating CRT, short-course RT with a 6-8-week delay is an alternative. If organ preservation is a goal, a first evaluation should preferably be carried out after about 6 weeks, with planned surgery for week 8 if the response is inadequate. In case the response is good, a new evaluation should be carried out after about 12 weeks, with a decision to start a 'watch-and-wait' programme or operate. Chemotherapy in the waiting period is an interesting option, and has been the subject of recent trials with promising results.
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Affiliation(s)
- Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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de Jong R, Lutkenhaus L, van Wieringen N, Visser J, Wiersma J, Crama K, Geijsen D, Bel A. Plan selection strategy for rectum cancer patients: An interobserver study to assess clinical feasibility. Radiother Oncol 2016; 120:207-11. [DOI: 10.1016/j.radonc.2016.07.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
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