Radiation for Colon and Rectal Cancer


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Radiation for Colon and Rectal Cancer

  1. 1. Radiation and ColorectalCancerRobert Miller MDwww.aboutcancer.com
  2. 2. NCCN.org
  3. 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. 4. Workup or Evaluation Prior to Decidingon Treatment for Colon Cancer
  5. 5. Workup or Evaluation Prior to Decidingon Treatment for Rectal Cancer
  6. 6. Accuracy of Imaging in StagingRectal CancerSite Ultrasound CT MRITumor 80-95% 65-75% 75-85%Nodes 70-75% 55-65% 60-65%
  7. 7. T2 T3NodesTransrectal Endoscopic Ultrasound (TEUS)
  8. 8. Radiation can safely cover the siteswhere rectal cancer is most likelyto recur3D reconstruction of sites of relapse in patients with rectal cancer
  9. 9. Radiation can safely expand the‘surgical resection’ volume
  10. 10. surgeryRadiationfieldRadiation can safely expand the‘surgical resection’ volume
  11. 11. Radiation TechniqueCT scan is obtained at the time ofsimulationCT images are then importedinto the treatment planningcomputer
  12. 12. In the simulationprocess the CTand PET scanimages are usedto create acomputer plan
  13. 13. Imaging rectal cancer radiation fieldsPortal image (x-rayimage showing thearea of radiation (lightblue)Computer generatedradiation target (dark blue)
  14. 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. 15. RadiationTargets orFields
  16. 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. 17. Radiation dose clouds are tailored to theareas that are at risk
  18. 18. Computer generated images and thesize of the radiation cloud around thesestructures
  19. 19. CT andPET scanfor manwithlocallyadvancedrectalcancer
  20. 20. Woman withlow rectalcancer, onultrasoundthe stagewas T3N1
  21. 21. PETScansEarlyRectalCancerLocallyAdvancedRectalCancerinto lymphnodes
  22. 22. Using PET Scan to identify site of rectalcancercancerrectumprostatepubicbonebladdersmallbowel
  23. 23. Computer generated images to matchthe PET scan
  24. 24. PET scan images are used to target theareas that need radiation
  25. 25. Original PET scan showing area ofcancerComputer generated images withradiation
  26. 26. PETscanimagesare usedto targetthe areasthat needradiation
  27. 27. Radiation Dose Fields Surroundthe Cancer
  28. 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. 29. Techniques to minimize radiation side effects
  30. 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. 31. Improved Outcome after Surgery byAdding ChemoradiationGastrointestinal Tumor Study GroupN Engl J Med 1985; 312:1465-1472
  32. 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. 33. Chemo-Radiation will often shrink thecancer making surgery easier
  34. 34. Chemo-Radiation will often shrink thecancer making surgery easier
  35. 35. Appearance ofadvanced rectal cancerat colonoscopy beforechemoradiationAppearance afterPreOp Chemoradiation forLocally Advanced Rectal Cancer
  36. 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. 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. 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. 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. 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. 41. Palliative radiation Local pelvic relapses Liver metastases Distant metastases
  42. 42. Palliating Pelvic Relapses Pain response rates in 64 – 85%range One series complete relief wasbleeding (100%) pain (65%) mass24%
  43. 43. Recurrent Colon Cancer withUnresectable Mesenteric Mass
  44. 44. Recurrent Mass surroundedby loops of normal bowel
  45. 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. 46. Using image guided IMRT can better target thecancer and limit the dose to normal structures
  47. 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. 48. Low Dose Radiation for LiverMetastases (40 – 80%)
  49. 49. Radiosurgery for Cancer
  50. 50. Radiosurgery for Liver Mets
  51. 51. Radiosurgery for Liver Mets
  52. 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. 53. Whole brain radiation
  54. 54. Typical response for whole brain radiation
  55. 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. 56. Bone Metastases and RadiationBefore XRT 3 months after XRT
  57. 57. Radiation and ColorectalCancerRobert Miller MDwww.aboutcancer.com