Definitive radical external beam radiotherapy for rectal cancer: Evaluation of local effectiveness and risk of late small bowel damage

Sprawka, Arkadiusz; Pietrzak, L.; Garmol, Dariusz; Tyc-Szczepaniak, Dobromira; Kępka, Lucyna; Bujko, Krzysztof

doi:10.3109/0284186x.2012.707786

Cited by 12 publications

(11 citation statements)

References 28 publications

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“…CRs were seen and a small but definite proportion was cured (13). This has also recently been reported from a Polish group; large fixed or locally recurrent tumors could be controlled with acceptable risks of late bowel toxicity (77). …”

Section: Increasing the Dose And/or Adding Chemotherapy In The Intervalsupporting

confidence: 63%

“…The radiation doses given then were as high as they can be today even if the tumor could be not be precisely located and delivery not so conformed as today. Thus, the expected toxicity today is less (77). A fluoropyrimidine was added as radiation sensitizer already in those days when the wish was to reach as high cell kill effect as possible, although the acute toxicity often prevented its use throughout the treatment in elderly patients.…”

Section: Discussionmentioning

confidence: 99%

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Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer?

Glimelius

2014

Front. Oncol.

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Background: In rectal cancer therapy, radiotherapy or chemoradiotherapy (RT/CRT) is extensively used pre-operatively to (i) decrease local recurrence risks, (ii) allow radical surgery in non-resectable tumors, and (iii) increase the chances of sphincter-saving surgery or (iv) organ-preservation. There is a growing interest among clinicians and scientists to prolong the interval from the RT/CRT to surgery to achieve maximal tumor regression and to diminish complications during surgery.Methods: The pros and cons of delaying surgery depending upon the aim of the pre-operative RT/CRT are critically evaluated.Results: Depending upon the clinical situation, the need for a time interval prior to surgery to allow tumor regression varies. In the first and most common situation (i), no regression is needed and any delay beyond what is needed for the acute radiation reaction in surrounding tissues to wash out can potentially only be deleterious. After short-course RT (5Gyx5) with immediate surgery, the ideal time between the last radiation fraction is 2–5 days, since a slightly longer interval appears to increase surgical complications. A delay beyond 4 weeks appears safe; it results in tumor regression including pathologic complete responses, but is not yet fully evaluated concerning oncologic outcome. Surgical complications do not appear to be influenced by the CRT-surgery interval within reasonable limits (about 4–12 weeks), but this has not been sufficiently explored. Maximum tumor regression may not be seen in rectal adenocarcinomas until after several months; thus, a longer than usual delay may be of benefit in well responding tumors if limited or no surgery is planned, as in (iii) or (iv), otherwise not.Conclusion: A longer time interval after CRT is undoubtedly of benefit in some clinical situations but may be counterproductive in most situations. After short-course RT, long-term results from the clinical trials are not yet available to routinely recommend an interval longer than 2–5 days, unless the tumor is non-resectable at diagnosis.

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Section: Increasing the Dose And/or Adding Chemotherapy In The Intervalsupporting

confidence: 63%

Section: Discussionmentioning

confidence: 99%

Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer?

Glimelius

2014

Front. Oncol.

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“…Other studies that have explored late small bowel toxicity have had large inconsistencies with fractionation schedule and the type of radiation therapy used. 7 , 8 , 9 , 10 …”

Section: Discussionmentioning

confidence: 99%

“…Previously published studies involved different fractionation schedules and non-IMRT radiation therapy, thus creating challenges in establishing guidelines that minimize late small bowel toxicity in IMRT treatment with higher maximum point dosages than the generally accepted 45 Gy. 7 , 8 , 9 , 10 Such guidelines are especially important in cases in which treatment of the underlying malignancy might benefit from more aggressive abdominal or pelvic radiation therapy.…”

Section: Introductionmentioning

confidence: 99%

Late small bowel toxicity after aggressive abdominopelvic intensity modulated radiation therapy

Ling

Furhang

Ryemon

et al. 2017

Advances in Radiation Oncology

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PurposeWe retrospectively analyzed late small bowel toxicity in patients who received abdominal or pelvic intensity modulated radiation therapy (IMRT) to the small bowel with a maximum dose greater than the generally accepted maximal tolerable dose of 45 Gy.Methods and materialsAll patients (N = 94) who received IMRT with a point dose of at least 45 Gy to tightly contoured small bowel between 2005 and 2014 at our institution were included. The median prescribed treatment dose was 70.2 Gy. The median follow-up was 20.1 months. Late small bowel toxicity was assessed using the Common Terminology Criteria for Adverse Events Version 3.0. Dosimetric variables and clinical factors were assessed for their relationship to small bowel toxicity.ResultsThe median maximal small bowel point dose (Dmax) was 6546.5 cGy. The estimated 5-year rates of freedom from at least grade 1, at least grade 2, and at least grade 3 late small bowel toxicity were 72.4% (95% confidence interval [CI], 60.7%-86.5%), 91.9% (95% CI, 84.1%-100%), and 93.6% (95% CI, 86.2%-100%), respectively. One patient (1.1%) developed grade 3 late toxicity, and 2 patients (2.1%) developed grade 4 late toxicity. Use of capecitabine/5-fluorouracil treatment was a significant predictor (P < 0.001) of at least grade 1 and at least grade 2 small bowel toxicity. No other clinical factors were associated with toxicity. None of the dose-volume parameters were significant predictors of small bowel toxicity.ConclusionIt may be possible with IMRT to deliver high doses to small volumes of small bowel with low rates of significant long-term complications. Further studies should explore tolerable dose-volume relationships in cases in which aggressive abdominal or pelvic treatment may be warranted to treat the underlying malignancy.

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“…Whether a single fraction of about 8 Gy or the short-course schedule 5 Â 5 Gy is the best schedule for palliation is not known, but 5 Â 5 Gy when given to patients not eligible for surgery or with synchronous metastases, symptomatic relief has often been seen [45,46]. In selected patients, higher and potentially curative doses up to about 60 Gy can be safely given and may result in good tumor control [47]. Whether interstitial pulsed dose rate brachytherapy as a complement to external CRT in locally advanced/ugly or recurrent rectal cancers will improve outcome is not known [43].…”

Section: Modifying the Time Interval To Surgerymentioning

confidence: 99%

What is most relevant in preoperative rectal cancer chemoradiotherapy – the chemotherapy, the radiation dose or the timing to surgery?

Glimelius

2016

Acta Oncologica

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Definitive radical external beam radiotherapy for rectal cancer: Evaluation of local effectiveness and risk of late small bowel damage

Cited by 12 publications

References 28 publications

Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer?

Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer?

Late small bowel toxicity after aggressive abdominopelvic intensity modulated radiation therapy

What is most relevant in preoperative rectal cancer chemoradiotherapy – the chemotherapy, the radiation dose or the timing to surgery?

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