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Radiation for Colon and Rectal Cancer


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  • 1. Radiation and ColorectalCancerRobert Miller
  • 2.
  • 3. Treatment of colorectalcancer• Early stages are treated with surgery• More advanced stages have surgery followedby chemotherapy (colon) or radiation andchemotherapy prior to surgery (rectum)• Metastatic or recurrent disease treated withchemotherapy or targeted therapy andpossibly radiation, some patients benefit fromsurgical resection or RF ablation
  • 4. Workup or Evaluation Prior to Decidingon Treatment for Colon Cancer
  • 5. Workup or Evaluation Prior to Decidingon Treatment for Rectal Cancer
  • 6. Accuracy of Imaging in StagingRectal CancerSite Ultrasound CT MRITumor 80-95% 65-75% 75-85%Nodes 70-75% 55-65% 60-65%
  • 7. T2 T3NodesTransrectal Endoscopic Ultrasound (TEUS)
  • 8. Radiation can safely cover the siteswhere rectal cancer is most likelyto recur3D reconstruction of sites of relapse in patients with rectal cancer
  • 9. Radiation can safely expand the‘surgical resection’ volume
  • 10. surgeryRadiationfieldRadiation can safely expand the‘surgical resection’ volume
  • 11. Radiation TechniqueCT scan is obtained at the time ofsimulationCT images are then importedinto the treatment planningcomputer
  • 12. In the simulationprocess the CTand PET scanimages are usedto create acomputer plan
  • 13. Imaging rectal cancer radiation fieldsPortal image (x-rayimage showing thearea of radiation (lightblue)Computer generatedradiation target (dark blue)
  • 14. Sites of Relapse in RedBased on the location ofthe most common sites fora relapse after surgery theradiation field in greenshould be large enough tocover these areas
  • 15. RadiationTargets orFields
  • 16. Radiation Fields• Include the tumor and tumor bed witha 2 to 5cm margin• Include the presacral nodes and internal iliac nodes• Include the external iliac nodes if T4 involvinganterior structures• Top: Usually L5-S1 or 1.5cm above sacralpromontory and the bottom 4 to 5cm below edge oftumor• Posterior 1cm behind the sacrum and anterior thepost wall of the vagina or a large portion of theprostate
  • 17. Radiation dose clouds are tailored to theareas that are at risk
  • 18. Computer generated images and thesize of the radiation cloud around thesestructures
  • 19. CT andPET scanfor manwithlocallyadvancedrectalcancer
  • 20. Woman withlow rectalcancer, onultrasoundthe stagewas T3N1
  • 21. PETScansEarlyRectalCancerLocallyAdvancedRectalCancerinto lymphnodes
  • 22. Using PET Scan to identify site of rectalcancercancerrectumprostatepubicbonebladdersmallbowel
  • 23. Computer generated images to matchthe PET scan
  • 24. PET scan images are used to target theareas that need radiation
  • 25. Original PET scan showing area ofcancerComputer generated images withradiation
  • 26. PETscanimagesare usedto targetthe areasthat needradiation
  • 27. Radiation Dose Fields Surroundthe Cancer
  • 28. PET Scan will also show ifthe cancer has spreadelsewhere in the body suchas the lymph nodes or liverThis case show areas ofliver metastases so thepatient would be classifiedas having stage IV rectalcancer and would needchemotherapy
  • 29. Techniques to minimize radiation side effects
  • 30. Benefit of Combining chemoradiationwith surgery for rectal cancer• Will lower the risk of a localrecurrence in the pelvic region andimprove survival• If given prior to surgery may help thesurgeon avoid a permanentcolostomy• If given before surgery may be lesscomplications than if given aftersurgery
  • 31. Improved Outcome after Surgery byAdding ChemoradiationGastrointestinal Tumor Study GroupN Engl J Med 1985; 312:1465-1472
  • 32. German Trial of PreOp or PostOpChemoradiation for Rectal CancerNEJM 2004;351:1731Outcome PreOp PostOpSurvival 76% 74%Local Relapse 6% 13%Complication 27% 40%
  • 33. Chemo-Radiation will often shrink thecancer making surgery easier
  • 34. Chemo-Radiation will often shrink thecancer making surgery easier
  • 35. Appearance ofadvanced rectal cancerat colonoscopy beforechemoradiationAppearance afterPreOp Chemoradiation forLocally Advanced Rectal Cancer
  • 36. PreOp Chemoradiation for Locally AdvancedRectal Cancer and Sphincter PreservationShrink the size or bulkof the tumor A to B tomake surgery easierShrink thelocation awayfrom the sphinctermaking surgerypossible
  • 37. Benefits of preOp chemoradiation forRectal Cancer in Avoiding aPermanent ColostomyIn series where patients were expectedto require a colostomy, after preOptherapy the number who were able toavoid a permanent colostomy (sphincterpreservation) in such reports rangesfrom 39 to 94 percent, averaging 67percent
  • 38. Typical Course of Preoperative radiation• Daily radiation (Monday through Friday) 5 days a week for 28treatments (so 5 and half weeks• Treatments generally take about 10 minutes• Radiation is combined with daily chemotherapy (usually continuousIV infusion of 5FU)• Side effects typically show up after the second week and fade awaystarting a week or two after completion• Surgery is generally scheduled 3 to 6 weeks after completing theradiation• Further chemotherapy is often given after surgery
  • 39. Side Effects of Pelvic RadiationRadiation fieldsRadiation may hit the smallbowel causing somecramps, diarrhea and fatigueFatigue, diarrhea, loss of appetite and rectalirritation are very common during the combinedchemoradiation period
  • 40. Side Effects of Pelvic RadiationRadiation fieldsRadiation may hit thebladder and rectum causingurinary burning or frequencyand rectal irritationIn pre-menopausal women, radiation is likely to effectovarian function and should not be used if the woman ispregnant
  • 41. Palliative radiation Local pelvic relapses Liver metastases Distant metastases
  • 42. Palliating Pelvic Relapses Pain response rates in 64 – 85%range One series complete relief wasbleeding (100%) pain (65%) mass24%
  • 43. Recurrent Colon Cancer withUnresectable Mesenteric Mass
  • 44. Recurrent Mass surroundedby loops of normal bowel
  • 45. Combine a CT scan and linear accelerator to ultimate intargeting (IGRT) and ultimate in delivery (dynamic, helicalIMRT) ability to daily adjust the beam (ART or adaptiveradiotherapy)Image Guided (IGRT) and IntensityModulated Radiation Therapy (IMRT
  • 46. Using image guided IMRT can better target thecancer and limit the dose to normal structures
  • 47. Clinical outcomes using stereotactic bodyradiotherapy for abdominopelvic tumors.Department of Radiation Oncology, MayoClinicTumor responses of the 48 target werecomplete response in 18 lesions (36%), partialresponse in 12 lesions (24%), stable diseasein 12 lesions (24%), and progressive diseasein 6 lesions (12%).So 60% responseAm J Clin Oncol. 2012 Dec;35(6):537-42.
  • 48. Low Dose Radiation for LiverMetastases (40 – 80%)
  • 49. Radiosurgery for Cancer
  • 50. Radiosurgery for Liver Mets
  • 51. Radiosurgery for Liver Mets
  • 52. A phase I/II dose-escalation trial ofCyberknife radiation for control of primaryor metastatic liver diseaseEarly toxicity has been mild with 3 patients (13%) experiencing grade 2 orgreater toxicity. In the 21 patients with >3 month follow-up, 3 (14%) haveexperienced a late toxicity. There have been 6 local recurrences. The lesionlocal recurrence rate is 17% and the patient local recurrence rate is 25%.Mean time to recurrence was 8.4 months.Conclusion: Cyberknife radiation can be delivered safely in doses up to 30Gy in a single fraction. Accrual of long-term local control and toxicity data isongoing.
  • 53. Whole brain radiation
  • 54. Typical response for whole brain radiation
  • 55. Radiosurgery for Brain Metastasesfrom colorectal Cancer152 patients with 616 tumors for metastatic braintumors from colorectal cancerThe primary tumors were located in the colon in 88patients and the rectum in 64.The local tumor growth control rate, based on MRimaging, was 91.2%Cause of death was systemic in 90% and brain 10%J Neurosurg. 2011 Mar;114(3):782-9
  • 56. Bone Metastases and RadiationBefore XRT 3 months after XRT
  • 57. Radiation and ColorectalCancerRobert Miller