Assessment and clinical validation of margins for adaptive simultaneous integrated boost in neo-adjuvant radiochemotherapy for rectal cancer

Raso, R.; Scalco, Elisa; Fiorino, Claudio; Broggi, S.; Cattaneo, Giovanni Mauro; Garelli, S.; Pagliazzi, Marco; Slim, N.; Muzio, N. Di; Rizzo, Giovanna; Calandrino, R.; Passoni, P.

doi:10.1016/j.ejmp.2014.12.002

Cited by 18 publications

(10 citation statements)

References 26 publications

(25 reference statements)

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“…Passoni et al and Raso et al [31,32] also reported on an adaptive procedure, but applied to the boost of the residual tumor during the last 6 fractions of LCRT. Byskov et al [33] describe an adaptive approach to re-irradiation of rectal recurrence.…”

Section: Discussionmentioning

confidence: 99%

Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy

et al. 2020

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Background: To compare target coverage and dose to the organs at risk in two approaches to rectal cancer: a clinically implemented adaptive radiotherapy (ART) strategy using plan selection, and a non-adaptive (non-ART) strategy. Methods: The inclusion of the first 20 patients receiving adaptive radiotherapy produced 10 patients with a long treatment schedule (25x2Gy) and 10 patients with a short schedule (5X5Gy). We prepared a library of three plans with different anterior PTV margins to the upper mesorectum, and selected the most appropriate plan on daily Conebeam CT scans (CBCT). We also created a non-adaptive treatment plan with a 20 mm margin. Bowel bag, bladder and target volume were delineated on CBCT. Daily DHVs were calculated based on the dose distribution of the selected and non-adaptive plans. Coverage of the target volume was compared per fraction between the ART and non-ART plans, as was the dose to the bladder and small bowel, assessing the following dose levels: V15Gy, V30Gy, V40Gy, V15Gy and V95% for long treatment schedules, and V15Gy and V95% for short ones. Results: Target volume coverage was maintained from 98.3% (non-ART) to 99.0% (ART)(p = 0.878). In the small bowel, ART appeared to have produced significant reductions in the long treatment schedule at V15Gy, V40Gy, V45Gy and V95% (p < 0.05), but with small absolute differences. The DVH parameters tested for the short treatment schedule did not differ significantly. In the bladder, all DVH parameters in both schedules showed significant reductions (p < 0.05), also with small absolute differences. Conclusions: The adaptive treatment maintained target coverage and reduced dose to the organs at risk. Trial registration: Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center, W19_194 # 19.233.

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Section: Discussionmentioning

confidence: 99%

Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy

et al. 2020

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“…A group of 65 patients with rectal adenocarcinoma whose clinical and imaging data were fully available, was considered: characteristics of the patients have already been reported [19] and are summarized in the Supplementary material. In short, all patients were treated within our ART observational study approved by the Institute Board [23], [25] in the period 2009–2016: all patients previously signed an informed consent. The concomitant chemotherapy consisted of Oxaliplatin 100 mg/m 2 on days −14, 0 (being day 0 the start of radiotherapy), and +14, and 5-fluoroacil (5-FU) 200 mg/m 2 /d from day −14 to the end of radiotherapy.…”

Section: Methodsmentioning

confidence: 99%

“…Tumor regression during therapy, although less investigated [17], [18], [19], [23], [24], [25], has been shown to be correlated with pathological response as well, with the advantage to give a prediction during the treatment and consequently to increase the potentials of response-driven treatment personalization. Moreover, tumor regression during RCT has also been successfully exploited by our group to implement early-regression guided adaptive boosting therapy [19], [23] with great potentials for treatment intensification aiming to increase the rate of pCR [26], similarly to what recently reported with image-guided brachytherapy boosting [27].…”

Section: Introductionmentioning

confidence: 99%

Accurate outcome prediction after neo-adjuvant radio-chemotherapy for rectal cancer based on a TCP-based early regression index

Fiorino

Passoni

Palmisano

et al. 2019

Clinical and Translational Radiation Oncology

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Background and purpose: An early tumor regression index (ERI TCP) was previously introduced and found to predict pathological response after neo-adjuvant radio-chemotherapy of rectal cancer. ERI TCP was tested as a potential biomarker in predicting long-term disease-free survival. Materials and methods: Data of 65 patients treated with an early regression-guided adaptive boosting technique (ART) were available. Overall, loco-regional relapse-free and distant metastasis-free survival (OS, LRFS, DMFS) were considered. Patients received 41.4 Gy in 18 fractions (2.3 Gy/fr), including ART concomitant boost on the residual GTV during the last 6 fractions (3 Gy/fr, D mean : 45.6 Gy). Chemotherapy included oxaliplatin and 5-fluorouracil (5-FU). T2-weighted MRI taken before (MRI pre) and at half therapy (MRI half) were available and GTVs were contoured (V pre , V half). The parameter ERI TCP = Àln[(1 À (V half /V pre)) Vpre ] was calculated for all patients. Cox regression models were assessed considering several clinical and histological variables. Cox models not including/including ERI TCP (CONV_model and REGR_model respectively) were assessed and their discriminative power compared. Results: At a median follow-up of 47 months, OS, LRFS and DMFS were 94%, 95% and 78%. Due to too few events, multivariable analyses focused on DMFS: the resulting CONV_model included pathological complete remission or clinical complete remission followed by surgery refusal (HR: 0.15, p = 0.07) and 5-FU dose >90% (HR: 0.29, p = 0.03) as best predictors, with AUC = 0.75. REGR_model included ERI TCP (HR: 1.019, p < 0.0001) and 5-FU dose >90% (HR: 0.18, p = 0.005); AUC was 0.86, significantly higher than CONV_model (p = 0.05). Stratifying patients according to the best cutoff value for ERI TCP and to 5-FU dose (> vs <90%) resulted in 47-month DMFS equal to 100%/69%/0% for patients with two/one/zero positive factors respectively (p = 0.0002). ERI TCP was also the only variable significantly associated to OS (p = 0.01) and LRFS (p = 0.03). Conclusion: ERI TCP predicts long-term DMFS after radio-chemotherapy for rectal cancer: an independent impact of the 5-FU dose was also found. This result represents a first step toward application of ERI TCP in treatment personalization: additional confirmation on independent cohorts is warranted.

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“…be guided by response to induction chemotherapy, as investigated by Seierstad and colleagues (14), or by response part-way through the radiotherapy treatment course (20). The group at the San Raffaele Scientific Institute in Milan has done particularly interesting work, including investigation of the use of optimized treatment margins for safe delivery of an adaptive SIB during the second half of the treatment course (20,38,39).…”

Section: Treatment Intensification Driven By Imrt / Vmatmentioning

confidence: 99%

Technological advances in radiotherapy of rectal cancer: opportunities and challenges

Appelt

Sebag‐Montefiore

2016

Current Opinion in Oncology

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Purpose of review:This review summarizes the available evidence for the use of modern radiotherapy techniques for chemoradiotherapy (CRT) for rectal cancer, with specific focus on intensity-modulated radiotherapy (IMRT) and volumetric arc therapy (VMAT) techniques. Recent findings:The dosimetric benefits of IMRT and VMAT are well-established, but prospective clinical studies are limited, with phase I-II studies only. Recent years have seen the publication of a few larger prospective patient series as well as some retrospective cohorts, several of which include much needed late toxicity data. Overall results are encouraging, as toxicity levels although varying across reports appear lower than for 3D conformal radiotherapy. Innovative treatment techniques and strategies which may be facilitated by the use of IMRT/VMAT include simultaneously integrated tumour boost, adaptive treatment, selective sparing of specific organs to enable chemotherapy escalation, and non-surgical management. Summary:Few prospective studies of IMRT and VMAT exist, which causes uncertainty not just in regards to the clinical benefit of these technologies but also in the optimal use. The priority for future research should be subgroups of patients who might receive relatively greater benefit from innovative treatment techniques, such as patients receiving CRT with definitive intent and patients treated with dose escalation.

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Assessment and clinical validation of margins for adaptive simultaneous integrated boost in neo-adjuvant radiochemotherapy for rectal cancer

Cited by 18 publications

References 26 publications

Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy

Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy

Accurate outcome prediction after neo-adjuvant radio-chemotherapy for rectal cancer based on a TCP-based early regression index

Technological advances in radiotherapy of rectal cancer: opportunities and challenges

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