Modified simultaneous integrated boost radiotherapy for an unresectable huge refractory pelvic tumor diagnosed as a rectal adenocarcinoma

Nomiya, Takuma; Akamatsu, Hiroko; Harada, Masaru; Ota, Ibuki; Hagiwara, Yasuhito; Ichikawa, Mayumi; Miwa, Misako; Kawashiro, Shohei; Hagiwara, Motohisa; Chin, Masahiro; Hashizume, Eiji; Nemoto, Kenji

doi:10.3748/wjg.v20.i48.18480

Cited by 7 publications

(15 citation statements)

References 34 publications

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“…Recently, a modified-SIB technique—focusing on intratumor dose escalation—has been reported to induce more significant tumor regression in several unresectable bulky tumors, such as huge pelvic mass, [ 50 ] retroperitoneal mass, [ 51 ] breast masses, [ 52 ] and liver tumors. [ 53 ] In the present case, we used a similar modified SIB by incorporating VMAT, i.e., SIEB-VMAT.…”

Section: Discussionmentioning

confidence: 99%

Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma

et al. 2016

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Background:Clinically, elderly patients with unresectable bulky hepatocellular carcinoma (HCC) are difficult to manage, especially in those with co-infections of hepatitis B and C virus. Herein, we reported such a case treated with radiotherapy (RT) by using combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy (SIEB-VMAT). After RT, significant symptoms alleviation and durable tumor control were observed.Case Summary:At presentation, an 85-year-old male patient complained abdominal distention/pain, poor appetite, and swelling over bilateral lower limbs for 1 month. On physical examination, a jaundice pattern was noted. Laboratory studies showed impaired liver and renal function. Abdominal computed tomography (CT) revealed a 12.5-cm bulky tumor over the caudate lobe of the liver. Biopsy was done, and hepatocellular carcinoma (HCC) was reported histopathologically. As a result, AJCC stage IIIA (cT3aN0M0) and BCLC stage C were classified. Surgery, radiofrequency ablation (RFA), trans-catheter arterial chemoembolization (TACE), and sorafenib were not recommended because of his old age, central bulky tumor, and a bleeding tendency. Thus, RT with SIEB-VMAT technique was given alternatively. RT was delivered in 26 fractions, with dose gradience as follows: 39 Gy on the outer Plan Target Volume (PTV), 52 Gy in the middle PTV, and 57.2 Gy in the inner PTV. Unexpectedly, cyproheptadine (a newly recognized potential anti-HCC agent) was retrospectively found to be prescribed for alleviating skin itching and allergic rhinitis since the last 2 weeks of the RT course (2 mg by mouth Q12h for 24 months).After RT, significant symptoms alleviation and tumor volume reduction were observed for 32 months till multiple bone metastases. Before and after RT, a large tumor volume reduction rate of 88.7% was observed (from 608.4 c.c. to 68.7 c.c.). No severe treatment toxicity was noted during and after RT. The patient died due to aspiration pneumonia with septic shock at 4 months after bone metastases identified.Conclusions:SIEB-VMAT physically demonstrated double benefits of intratumor dose escalation and extra-tumor dose attenuation. Significant tumor regression and symptoms alleviation were observed in this elderly patient with unresectable bulky HCC. Further prospective randomized trials are encouraged to demarcate effective size of SIEB-VMAT with or without cyproheptadine.

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Section: Discussionmentioning

confidence: 99%

Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma

et al. 2016

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“…However, the dose distribution in the tumor is homogeneous in the standard SIB technique, and the dose received by the tumor usually does not exceed the tolerance dose of the surrounding healthy tissue. With the modified SIB technique, it is possible to irradiate the center of tumor with higher doses than the surrounding healthy tissue, by creating contrasts in the dose distribution in the tumor (27,28). This difference between the standard SIB technique and modified SIB technique is demonstrated in the present study.…”

Section: Discussionmentioning

confidence: 68%

“…Furthermore, as demonstrated by the present case, complete recovery can be achieved for patients who cannot undergo surgery due to the advanced nature of the tumor. Modified SIB radiotherapy may be used in abdominal tumors and also in tumors arising at other sites (27). Future challenges include the establishment of a technique for the use of modified SIB radiotherapy and increasing the number of enrolled patients.…”

Section: Discussionmentioning

confidence: 99%

Modified simultaneous integrated boost radiotherapy for large retroperitoneal malignant tumor: A case report

Nomiya¹,

Akamatsu

Harada³

et al. 2015

Oncology Letters

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Abstract. The current study reports the case of a large retroperitoneal tumor treated with modified simultaneous integrated boost (SIB) radiotherapy. A 45-year-old female presented to the emergency department complaining of left abdominal pain and fever. A computed tomography scan detected a retroperitoneal tumor of 12x16x16 cm, and a biopsy revealed a poorly-differentiated adenocarcinoma. The patient was diagnosed with a large adenocarcinoma originating from the left ureter, with no distant metastasis. Due to the patient's poor physical condition, surgery was not recommended, and the patient was referred to the Department of Radiation Oncology (Yamagata University Hospital, Yamagata, Japan). Modified SIB radiotherapy was administered following the acquisition of written consent from the patient. The total irradiation dose to the center of the tumor and to the surrounding healthy tissue was ~96 Gy/33 fractions and <60 Gy/33 fractions, respectively. At the end of the radiotherapeutic course, the tumor volume was reduced by ≥80%, and the residual tumor was surgically resected. As a result of the resection, a complete pathological response was confirmed; the patient has been recurrence-free for >3 years with no complications. Modified SIB radiotherapy may be safely administered, with favorable outcomes. Complete recovery can be achieved with this technique, even in a patient with a large radioresistant tumor. IntroductionRetroperitoneal tumors arise from the tissues of the retroperitoneal space, which includes the following structures: The adrenal glands, kidneys, ureter, aorta, inferior vena cava, pancreas (part), duodenum, colon (part), rectum, esophagus, lymph nodes, and soft tissue. Although in other sites the incidence of a benign tumor is higher than that of a malignant tumor, the incidence of a malignant tumor in the peritoneum is ~4 times higher than that of a benign tumor (1). The majority of retroperitoneal tumors are malignant soft tissue tumors, lymphoproliferative disorders, and malignancies arising from parenchymal tissues (1).Approximately one-third of retroperitoneal tumors are soft tissue sarcomas, with liposarcoma and leiomyosarcoma accounting for ~70% and 15% of reteroperitoneal sarcomas, respectively (2). The retroperitoneum is the second most common site of origin of soft tissue tumors (2), with 10-15% of soft tissue sarcomas arising from the retroperitoneum (3,4). More rarely, Castleman's tumors (5), adult neuroblastoma (6), gastrinoma (7), solitary fibrous tumor of the pancreas (8), teratoma (9) and neurogenic tumors (10) have been reported to occur in this region. Due to the rarity of retroperitoneal large adenocarcinoma, literature regarding the surgical treatment of large retroperitoneal tumors is limited (11). Furthermore, no standard treatment exists for patients with inoperable large retroperitoneal tumors and thus, only palliative chemotherapy or radiotherapy or best supportive care is administered for these patients.Retroperitoneal tumors show few clinical symptoms in the early phase,...

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“…This result enforces the choice of a significant boost dose to increase local control and alleviate symptoms because, in this context, the integral dose to healthy tissues do not represents a limiting factor. Recently, a similar approach has been proposed for the management of a breast cancer and large abdominal tumors …”

Section: Discussionmentioning

confidence: 99%

“…In particular, if the dose boost is a stereotactic‐like dose level, that is, an ablative dose, a partial ablative radiotherapy (PAR) has the potential to amplify both the antineoplastic and palliative effects, not only by improving the cell killing almost in a tumor subvolume, but also by activating immunological antineoplastic mechanisms . This strategy constitutes a modified SIB technique whose main point, as opposed to the widely used SIB technique, is to deliver the highest possible dose to a boost volume, limiting the dose to the healthy tissue to the tolerance dose …”

Section: Introductionmentioning

confidence: 99%

Partially ablative radiotherapy (PAR) for large mass tumors using simultaneous integrated boost: A dose‐escalation feasibility study

Cilla

Deodato

Ianiro

et al. 2018

J Applied Clin Med Phys

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PurposeThis study aimed to assess the feasibility to plan and deliver highly heterogeneous doses to symptomatic large tumors using volumetric modulated arc therapy (VMAT) and simultaneous integrated boost (SIB) during a short course palliative accelerated radiotherapy.MethodsA patient with a large symptomatic chordoma infiltrating the right gluteal region was selected. A modified SIB treatment was implemented to irradiate the central volume of the tumor (boost target volume, BTV) up to 10 Gy/fraction in a dose escalation trial while maintaining the remaining tumor volume (planning target volume, PTV) and the surrounding healthy tissues within 5 Gy/fraction in twice daily fractions for two consecutive days. Four SIB plans were generated in the dual‐arc modality; a basal dose of 20 Gy was prescribed to the PTV, while the BTV was boosted up to 40 Gy. For comparison purposes, plans obtained with a sequential boost (SEQ plans) were also generated. All plans were optimized to deliver at least 95% of the prescription dose to the targets. Dose contrast index (DCI), conformity index (CI), integral dose (ID), and the irradiated body volumes at 5, 10, and 20 Gy were evaluated.ResultsAt equal targets coverage, SIB plans provided major improvement in DCI, CI, and ID with respect to SEQ plans. When BTV dose escalated up to 200% of PTV prescription, DCI resulted in 66% for SIB plans and 37% for SEQ plans; the ID increase was only 11% for SIB plans (vs 27% for SEQ plans) and the increase in healthy tissues receiving more than 5, 10, and 20 Gy was less than 2%. Pretreatment dose verification reported a γ‐value passing rate greater than 95% with 3%(global)‐2 mm.ConclusionA modified SIB technique is dosimetrically feasible for large tumors, where doses higher than the tolerance dose of healthy tissues are necessary to increase the therapeutic gain.

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Modified simultaneous integrated boost radiotherapy for an unresectable huge refractory pelvic tumor diagnosed as a rectal adenocarcinoma

Cited by 7 publications

References 34 publications

Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma

Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma

Modified simultaneous integrated boost radiotherapy for large retroperitoneal malignant tumor: A case report

Partially ablative radiotherapy (PAR) for large mass tumors using simultaneous integrated boost: A dose‐escalation feasibility study

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