RADIOTHERAPY IN CARCINOMA ESOPHAGUS STOMACH RECTUM AND ANAL CANAL

1. ROLE OF RADIOTHERAPY IN GI
MALIGNANCIES
PRESENTER- DR.BRIJESH
MODERATOR- DR.PAVAN KUMAR

2. • ROLE OF RADIOTHERAPY IN
ESOPHAGEAL CARCINOMA

5. PATIENT POSITIONING
IMMOBILISATION
CT SIMULATION
RT IMAGING AND TARGET DILINEATION
RADIOTHERAPY PLANNING
TREATMENT DELIVERY

30. • ROLE OF RT IN GE JUNCTION

31. GE Junction
 The location of the GE junction can be defined histologically as the
squamocolumnar junction.
 In the most recent AJCC staging system, cancers with an epicenter in the lower
thoracic esophagus or gastroesophageal junction or within the proximal 2 cm of
the stomach (i.e., cardia) and extending up to the GE junction or esophagus are
staged as an adenocarcinoma of the esophagus.
 If the epicenter is >2 cm distal to the gastroesophageal junction, these are
classified as stomach cancers.
 Useful landmarks in reference to endoscopy include the carina (∼25 cm from the
incisors) and gastroesophageal junction (∼40 cm from the incisors).

32. MANAGEMENT
It includes
Surgery
Radiotherapy
Chemotherapy

33. ROLE OF RADIOTHERAPY
Radiotherapy may be given in multiple settings like
1.PRE OP (NEOADJUVANT) RADIATION THERAPY
2.ADJUVANT RADIATION THERAPY (POST OP)
3.RADIOTHERAPY ALONG WITH CHEMOTHERAPY
4.PALLIATIVE RADIOTHERAPY

34. Indications for Radiation Therapy
 Post op RT with concurrent and maintenance chemotherapy is
recommended for patient with stage IB-IV and M0 gastric cancer.
 For T2N0, Chemoradiation if it has
• Poorly differeniated
• LVSI+ve
• PNI +ve
• High grade disease
 RT with concomitant 5FU based chemotherapy for locally confined
gastric cancer that either is not technically resectable or occurs in
medically inoperable patients.
 Incomplete gastric resection.
 Positive surgical margins.

35. Preoperative Chemoradiation Versus
Preoperative Chemotherapy
 A randomized trial(Preoperative Chemotherapy, or Radiochemotherapy in
Esophagogastric Adenocarcinoma, or POET, trial 2016 ) comparing neoadjuvant
chemotherapy alone versus neoadjuvant combined-modality therapy was
conducted in patients with advanced esophagogastric adenocarcinoma.
 Patients were randomized to receive (a) cisplatin-/5-FU–based chemotherapy
alone versus (b) a similar induction chemotherapy, followed by concurrent
cisplatin/etoposide with 30 Gy of radiation therapy.
 Both groups went on to receive surgery.
 Patients receiving preoperative chemoradiotherapy had significantly higher N0
rates (37% vs. 64%) and pathologic complete response rates (2% vs. 16% ), as
well as significant trends toward improved local control (59% vs. 76%) and
overall survival (3-year survival, 28% vs. 47%).
Preoperative combined modality improves overall survival as
compared to chemotherapy alone in patients with locally advanced
esophagogastric adenocarcinoma.

36. CROSS Trial
Patients with clinically resectable, locally advanced cancer of the oesophagus or oesophagogastric junction
(clinical stage T1N1M0 or T2–3N0–1M0,) were randomly assigned in a 1:1 ratio to receive either weekly
administration of five cycles of neoadjuvant chemoradiotherapy (intravenous carboplatin [AUC 2 mg/mL per
min] and intravenous paclitaxel [50 mg/m² of body-surface area] for 23 days) with concurrent radiotherapy
(41·4 Gy, given in 23 fractions of 1·8 Gy on 5 days per week) followed by surgery, or surgery alone. The
primary endpoint was overall survival
After a median follow-up for surviving patients of 84 months median overall survival was 48
months in the neoadjuvant chemoradiotherapy plus surgery group and 24 months in the surgery
alone group

37. Postoperative Combined Chemoradiation
 A large randomized Intergroup trial 0116(Mc Donald Trail) evaluating the role of
adjuvant chemoradiation after surgery versus surgery alone for patients with
adenocarcinoma of the stomach and GE junction was reported.
 In this study, patients with resected, margin-negative gastric or gastroesophageal
junction adenocarcinoma were randomly assigned to surgery alone versus surgery
with postoperative chemoradiotherapy.
 Approximately 20% of patients had lesions in the gastroesophageal junction.
 A significant survival advantage was seen in the adjuvantly treated group (median
survival 27 vs. 36 months).
 Long-term results at >10-year median follow-up continued to show significant
improvement in overall and disease-free survival in the chemoradiation group,
 CONCLUSION- Adjuvant chemoradiotherapy potentially improve upon local
control and survival

38. Mc Donald Trial
559 patients with primaries > T3 and/or node-positive gastric cancer were randomly
assigned to Observation versus Radiochemotherapy after R0 resection.
Overall survival (OS) and relapse-free survival (RFS) data demonstrate continued
strong benefit from postoperative radiochemotherapy.

39. Intraoperative Radiation Therapy (IORT)
 The alternative approach to postoperative or preoperative
irradiation is intraoperative radiation therapy (IORT).
 The advantage of this technique is the ability to deliver a single
large fraction (10 to 35 Gy) of radiation to the tumor or tumor bed
while excluding or protecting surrounding normal tissue from the
high-dose field.
 This approach permits high-dose irradiation with minimal normal
tissue treatment.
 Even though IORT failed to afford a significant advantage over
conventional therapy in overall survival, it significantly improved
control of locoregional disease.
 The use of IORT in gastric cancer remains a topic of investigation.

40. Palliative Radiation Therapy
Radiation therapy is capable of providing
substantial palliation of local gastric cancer
symptoms like bleeding, pain, gastric outlet
obstruction and dysphagia in Ge junction tumors
A systematic review of the use of palliative
radiotherapy in gastric cancer showed large
variations in radiation dose and fractionation.
Palliative treatment regimens range from 20 Gy
over 1 week to 50 Gy over 5 weeks

41. Common nodal recurrent regions (green) overlapped by more than five recurrent nodal gross
tumor volumes depicted on a digitally reconstructed radiograph image.
The volume of total GTVs (yellow), liver (cobalt purple), and both kidneys (violet) are also seen.
Common hepatic artery (CHA), splenic artery (SA), left gastric artery (LGA), celiac artery (CA),
superior mesenteric artery (SMA), inferior mesenteric artery (IMA), and left renal vein (LRV) are
shown in solid lines.

42. RADIOTHERAPY VOLUME IN GE
JUNCTION TUMORS

43. Doses of Radiation
 Generally, doses in the range of 45 to 50.4 Gy should be delivered at 1.8 Gy per
fraction.
 For treatment of inoperable disease, this dose is followed by a 5.4- to 9-Gy cone-
down boost to GTV plus 1.5 cm to a total dose of 50.4–54 Gy.
 Parallel-opposed AP/PA fields are used and beneficial for tumor bed and nodal
irradiation.
 Obliqued or lateral portals can be used to deliver a 10- to 20-Gy component of
irradiation to spare spinal cord or Kidney.
 Patients should be treated with high-energy photons.
 Various Modalities of radiation are
 Conventional technique
 3DCRT
 IMRT
 IGRT
 IMRT may be appropriate to reduce doses to normal structures, including the
heart, liver, and Kidneys.

44. NEOADJUVANT CHEMOTHERAPY
 A more heterogeneous European study (the Medical Research
Council Adjuvant Gastric Infusional Chemotherapy, or MAGIC, trial)
randomly assigned patients with resectable adenocarcinoma of the
stomach, gastroesophageal junction, or lower esophagus to
preoperative and postoperative chemotherapy with epirubicin,
cisplatin, and 5-FU versus surgery alone.
 Approximately one-fourth of patients had adenocarcinoma
involving the lower esophagus or gastroesophageal junction.
 Five-year survival in patients receiving chemotherapy was 36%
versus 23% in patients undergoing surgery alone (P = .009).

45. Conclusion: Perioperative chemotherapy with a regimen of ECF improves OS and PFS
among patients with resectable adenocarcinoma of the stomach, lower esophagus,
or GE junction, as compared with surgery alone

46. NEOADJUVANT CHEMOTHERAPY

47. COMPLICATIONS OF RADIOTHERAPY AND
CHEMOTHERAPY
 Complication rates can exceed 75%, including pulmonary and cardiac
complications,
 Anastomotic leak, and recurrent laryngeal nerve paralysis.
 Esophagitis
 Dysphagia,
 Chemotherapy-related leukopenia and thrombocytopenia are common,
 Additional acute toxicities of radiation therapy include, dermatitis, fatigue, and
weight loss in most patients.
 Nausea and vomiting are relatively common, particularly in patients with lower
esophageal and gastroesophageal junction tumors.
 Many symptoms resolve within 1 to 2 weeks of treatment completion. A
perforated esophagus is life threatening and can be characterized by substernal
chest pain, a high pulse rate, fever, and hemorrhage.
 Chemotherapy-related leukopenia and thrombocytopenia may occur
 The most common late effects following radiation therapy are esophageal
stenosis and stricture formation.

48. Role Of Radiotherapy And
Chemotherapy In Carcinoma Rectum

49. Stage and Prognosis
Stage 5-year Survival (%)
0,I Tis,T1;No;Mo > 90
I T2;No;Mo 80-85
II T3-4;No;Mo 70-75
III T2;N1-3;Mo 70-75
III T3;N1-3;Mo 50-65
III T4;N1-2;Mo 25-45
IV M1 <3

50. Treatment
Surgery Chemotherapy Radiotherapy

51. Adjuvant Therapy: Rectal Cancer
• Adjuvant radiotherapy preop/post op significant increase in
loco-regional control .
• Sphincter sparing procedure; Organ preservation
• Role of adjuvant chemo-radiotherapy was evaluated to improve
treatment outcome.
• Decreases rate of local recurrence in locally advanced disease; as
tumor fixation is a limitation to surgery.
• No improvement with DFS and OS.

52. Adjuvant therapy
Chemotherapy
Radiation therapy
with or without
chemotherapy

53. Indications of radiotherapy
• Adjuvant radiotherapy
Pre op: Stage 2 or stage 3
Post op: high risk histopath ≥ pT3,N+,LVSI,Margin
positivity
• Palliative radiotherapy: Symptom based
management
Haemostatic Radiotherapy
Local palliative Radiotherapy
Bone metastasis
Cord compression
Brain metastasis

54. • Down staging the disease, hence increased resectability
• Decreased risk of dissemination during surgery.
• Radiation therapy is more biologically effective if tumour cells
have intact vascularity.
• Less serious bowel toxicity due to easy exclusion.
• Possibility of increasing sphincter preservation in borderline
cases.
Evaluation of patients on basis of pathological features not possible.
ADVANTAGES OF PRE OP CT+RT

55. Techniques of Radiotherapy
• Conventional
– Based on bony landmarks
Posterior-anterior Portal Lateral Portal

56. Techniques of Radiotherapy
• Three dimensional conformal Radiotherapy
– Computed tomography imaging for three dimensional planning.
– Target and critical structure delineation Contouring of the
target volume including gross tumour volume ,clinical target
volume, planning target volume /OAR.

57. Techniques of Radiotherapy
• IMRT
– More conformal dose distribution
– Better sparing of organs at risk

58. Radiotherapy
 Positioning & immobilisation
•Supine/ Prone position: radio-
opaque markers include anal,
vaginal, rectal, perineal skin; wire
perineal scar if present; small
bowel contrast, ensure bladder
full.
• Pelvic thermoplastic cast
•Prone position with belly board
•Purpose is to displace bowel
superior and anteriorly &
bladder anteriorly
CECT simulation

59. Radiotherapy
Target volumes:
•Primary tumour + clinically +ve nodes >1cm or Tumor bed with margin.
•Entire mesorectum.
•Spread to other organ - sacrum, vagina or prostate
•Whole of the sacrum
•Lymph nodes (presacral, internal iliac nodes (if T4, external iliac nodes also).

60. Dose
 Preoperative radiotherapy
– Short course: 25 Gy in 5 daily fractions of 5 Gy given in 1 week.
– Long course
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy
 Postoperative radiotherapy adjuvant* : 50.4Gy/28Fr/5.5 wk
*high risk histopath features ≥ pT3, N+, LVSI, Margin positivity
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy.

61. • Palliative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–14.4 Gy in 3–8 daily fractions of 1.8 Gy OR
 Hypofractionated regimen can be used: 30–36 Gy in 5–6
fractions of 6 Gy once weekly given in 5–6 weeks.
• Dose limitations (at standard fractionation )
– Small bowel 45–50 Gy
– Femoral head and neck 42 Gy
– Bladder 65 Gy

62. Role Of Radiotherapy In Anal Canal
Carcinoma

63. TREATMENT OF LOCALIZED SQUAMOUS
CELL CARCINOMA OF THE ANAL CANAL
• Until the late 1970s, the conventional
treatment for anal canal cancer was
an APR.
• Nigro et al. in 1974 challenged this
practice
 patients with squamous cell cancer of
the anal cancer who following
preoperative treatment with 30 Gy
plus concurrent fluorouracil (5-FU)
and mitomycin-C were found to have
a pathologic complete response at
the time of surgery.
• Combined Modality Therapy
has been the standard of care
since the 1980s,
• A review of 38,882 patients
with anal cancer---those treated
with CMT (plus surgery) had
higher 5-year survival rates
compared to those who did not
receive CMT (65% versus 58%, P
< .0001).

64. Surgery - Indications
• Has limited role in the primary treatment of
anal cancer
• Local excision can be considered only for
selected patients with well differentiated early-
stage tumors (T1N0M0)
• SCC that is <40% circumferential involvement
• No sphincter involvement
• Abdominal peritoneal resection (APR) is
reserved for salvage after primary
chemoradiotherapy failure

65. Radiation therapy - Indications
• EBRT with concurrent
chemotherapy is the
mainstay treatment for
localized anal cancer
• RT alone can be reserved for
stage T1N0M0 disease
• Palliation therapy to primary
or metastatic foci
Techniques
• EBRT using three-
dimensional conformational
RT(3D-CRT) or IMRT

66. RADIATION THERAPY
 Localization,
 Immobilization, and
 Simulation
• Supine with arms across the chest or
• Prone in a belly board ,arms extended.
• Bolus used in perineal region
• Contrast agents and markers
i. Oral contrast to delineate the small
bowel.
i. Barium enema to delineate the tumor.
ii. IV contrast to delineate the tumor and
LN.
iii. Anal marker is used to visualize the anal
verge.
iv. Wire to mark involved palpable inguinal
LN.
 A full bladder is recommended to
decrease toxicity to the small intestine.
 The penis is placed cranially to prevent
its bolus effect on the scrotum.
 Inguinal electron boost is applied in
the supine position.
 High energy X-rays (6–18 MV) are
used.
 Inguinal electron boost is applied with
suitable electron energies, and bolus
may be used if required.

67.  Anterior field until 36 Gy:
• Superior: above sacroiliac joints
• Inferior: below the anal verge or
3 cm below the tumor
• Lateral: medial side of the
trochanter major, including
inguinal lymph nodes
 Anterior field between 36 and
45 Gy
• Superior: below sacroiliac
joints.
• Inferior: below the anal verge or
3 cm below the tumor
• Lateral: tips of femur heads

68.  Posterior field until 45 Gy:
• Superior: above sacroiliac
joints
• Inferior: below the anal verge
or 3 cm below the tumor
• Lateral: tips of femur heads
 Anterior–posterior boost
field 50.4–54 Gy:
• Tumor/tumor bed + 2.5 cm
 Electron boosts are added to
inguinal regions
• LN (−): total dose is completed
to 45 Gy.
• LN (+): total dose is completed
to 50.4–54 Gy.

69. 3D CRT VOLUMES
• Target Volume Definitions
• GTV:- Primary tumor clinically positive LN seen on
planning CT (>1 cm short axis diameter).
I. PET or MRI fusion typically aides in GTV delineation.
II. Colonoscopy/anoscopy reports may help determine
tumor location.
• CTV:- LN at risk include common iliac, external iliac,
internal iliac, presacral, mesorectal, perianal, and
inguinal.
I. CTV = 2.5 cm expansion on primary tumor and 1 cm
expansion on involved nodes
• PTV = CTV + 1cm

70. Initial radiation fields (AP/PA) to cover
the entire pelvis

71. Cone-down radiation fields (AP/PA) to
cover the inferior pelvis

72. DOSE / FRACTIONATION (NCCN)
• Field reduction to cone down after 30.6 Gy.
• T3, T4, or T2 lesions with residual disease after 45 Gy should
receive an additional 9 to 14.4 Gy to the GTV via boost field.
• T2 dose goal, 45 to 50.4 Gy
• T3 dose goal, 54 Gy
• T4 dose goal, 54 to 59.4 Gy

73. Side Effects of Pelvic Radiation
Radiation fields
Radiation may hit the
small bowel causing
cramps, diarrhea and
fatigue
High dose area

74. Side Effects of Pelvic Radiation
Radiation fields
Radiation may hit the bladder and
rectum causing urinary burning or
frequency and ano-rectal irritation
and skin burning
High dose area
In pre-menopausal women, radiation is likely to effect
ovarian function and should not be used if the woman
is pregnant.

75. THANK YOU…….