What Are the Dose-Volume Constraints for Long-Course Radiochemotherapy to Apply for IMRT?

Chapter

Abstract

Preoperative radiochemotherapy (RCT) has been successfully adopted to reduce local recurrence rates in locally advanced rectal cancer. This benefit however has to be balanced against the acute and late side effects, of which radiation enteritis due to radiotherapy (RT) induced small bowel injury is the major source. A multitude of factors are influencing the tolerance of small bowel to radiation, including diabetes mellitus, pelvic inflammatory disease, prior abdominal or pelvic surgery, and the administration of concurrent chemotherapy. The major factors however are RT related and include mainly the total radiation dose and the volume of irradiated small bowel. Despite well-accepted and implemented measures such as distention of the urinary bladder, the use of the prone position, and a belly-board technique, the irradiated volume of small bowel can be reduced significantly only by using sophisticated forms of conformal RT such as intensity-modulated RT (IMRT), where geometrically shaped fields and varying intensities within the shaped field create a conformal dose distribution that tightly matches the target volume. Considering the concave shaped form of the planning target volume (PTV) with the small bowel and bladder lying in the middle, preoperative RT of rectal cancer represents a real challenge for IMRT. Dose-volume constraints have been of little relevance for 3D-conformal RT (3D-CRT) as the planner is configuring a variety of beams, wedges, and beamweights to end up in a suitable plan (called “forward planning”). In contrast, the complexity of IMRT requires the inverse and allows clinicians to specify dose-volume constraints to PTV as well as critical organs at risk (OAR) before the optimization is initiated (“inverse planning”). The following section proposes dose-volume constraints for the OARs in preoperative RT of rectal cancer based on available dose-response relationships (Table 24.1).

References

  1. 1.
    Baglan KL, Frazier RC, Yan D et al (2002) The dose-volume relationship of acute small bowel toxicity from concurrent 5-FU-based chemotherapy and radiation therapy for rectal cancer. Int J Radiat Oncol Biol Phys 52:176–183CrossRefPubMedGoogle Scholar
  2. 2.
    Robertson JM, Lockman D, Yan D et al (2008) The dose-volume relationship of small bowel irradiation and acute grade 3 diarrhea during chemoradiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 70:413–418CrossRefPubMedGoogle Scholar
  3. 3.
    Tho LM, Glegg M, Paterson J et al (2006) Acute small bowel toxicity and preoperative chemoradiotherapy for rectal cancer: investigating dose-volume relationships and role for inverse planning. Int J Radiat Oncol Biol Phys 66:505–513CrossRefPubMedGoogle Scholar
  4. 4.
    Gunnlaugsson A, Kjellen E, Nilsson P et al (2007) Dose-volume relationships between enteritis and irradiated bowel volumes during 5-fluorouracil and oxaliplatin based chemoradiotherapy in locally advanced rectal cancer. Acta Oncol 46:937–944CrossRefPubMedGoogle Scholar
  5. 5.
    Robertson JM, Söhn M, Yan D (2010) Predicting grade 3 acute diarrhea during radiation therapy for rectal cancer using a cutoff-dose logistic regression normal tissue complication probability model. Int J Radiat Oncol Biol Phys 77:66–72CrossRefPubMedGoogle Scholar
  6. 6.
    Yang TJ, Oh JH, Son CH et al (2013) Predictors of acute gastrointestinal toxicity during pelvic chemoradiotherapy in patients with rectal cancer. Gastrointest Cancer Res 6:129–136PubMedPubMedCentralGoogle Scholar
  7. 7.
    Roeske JC, Bonta D, Mell LK et al (2003) A dosimetric analysis of acute gastrointestinal toxicity in women receiving intensity-modulated whole-pelvic radiation therapy. Radiother Oncol 69:201–207CrossRefPubMedGoogle Scholar
  8. 8.
    Devisetty K, Mell LK, Salama JK et al (2009) A multi-institutional acute gastrointestinal toxicity analysis of anal cancer patients treated with concurrent intensity-modulated radiation therapy (IMRT) and chemotherapy. Radiother Oncol 93:298–301CrossRefPubMedGoogle Scholar
  9. 9.
    Reis T, Khazzaka E, Welzel G et al (2015) Acute small-bowel toxicity during neoadjuvant combined radiochemotherapy in locally advanced rectal cancer: determination of optimal dose-volume cut-off value predicting grade 2–3 diarrhoea. Radiat Oncol 10:30CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Letschert JG, Lebesque JV, de Boer RW et al (1990) Dose-volume correlation in radiation-related late small-bowel complications: a clinical study. Radiother Oncol 18:307–320CrossRefPubMedGoogle Scholar
  11. 11.
    Marks LB, Yorke ED, Jackson A et al (2010) Use of normal tissue complication probability models in the clinic. Int J Radiat Oncol Biol Phys 76:S10–S19CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    De Ridder M, Tournel K, Van Nieuwenhove Y et al (2008) Phase II study of preoperative helical tomotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 70:728–734CrossRefPubMedGoogle Scholar
  13. 13.
    Engels B, Platteaux N, Van den Begin R et al (2014) Preoperative intensity-modulated and image-guided radiotherapy with a simultaneous integrated boost in locally advanced rectal cancer: report on late toxicity and outcome. Radiother Oncol 110:155–159CrossRefPubMedGoogle Scholar
  14. 14.
    Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740CrossRefPubMedGoogle Scholar
  15. 15.
    Appelt AL, Bentzen SM, Jakobsen A et al (2015) Dose-response of acute urinary toxicity of long-course preoperative chemoradiotherapy for rectal cancer. Acta Oncol 54:179–186CrossRefPubMedGoogle Scholar
  16. 16.
    Engels B, Tournel K, Everaert H et al (2012) Phase II study of preoperative helical tomotherapy with a simultaneous integrated boost for rectal cancer. Int J Radiat Oncol Biol Phys 83:142–148CrossRefPubMedGoogle Scholar
  17. 17.
    Baxter NN, Habermann EB, Tepper JE et al (2005) Risk of pelvic fractures in older women following pelvic irradiation. JAMA 294:2587–2593CrossRefPubMedGoogle Scholar
  18. 18.
    Holm T, Singnomklao T, Rutqvist LE et al (1996) Adjuvant preoperative radiotherapy in patients with rectal carcinoma: adverse effects during long term follow-up of two randomized trials. Cancer 78:968–976CrossRefPubMedGoogle Scholar
  19. 19.
    Herman MP, Kopetz S, Bhosale PR et al (2009) Sacral insufficiency fractures after preoperative chemoradiation for rectal cancer: incidence, risk factors, and clinical course. Int J Radiat Oncol Biol Phys 74:818–823CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kim HJ, Boland PJ, Meredith DS et al (2012) Fractures of the sacrum after chemoradiation for rectal carcinoma: incidence, risk factors, and radiographic evaluation. Int J Radiat Oncol Biol Phys 84:694–699CrossRefPubMedGoogle Scholar
  21. 21.
    Tunio M, Al Asiri M, Bayoumi Y et al (2014) Lumbosacral plexus delineation, dose distribution, and its correlation with radiation-induced lumbosacral plexopathy in cervical cancer patients. Onco Targets Ther 8:21–27CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Yang TJ, Oh JH, Apte A et al (2014) Clinical and dosimetric predictors of acute hematologic toxicity in rectal cancer patients undergoing chemoradiotherapy. Radiother Oncol 113:29–34CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Mell LK, Schomas DA, Salama JK et al (2008) Association between bone marrow dosimetric parameters and acute hematologic toxicity in anal cancer patients treated with concurrent chemotherapy and intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 70:1431–1437CrossRefPubMedGoogle Scholar
  24. 24.
    Mell LK, Tiryaki H, Ahn KH et al (2008) Dosimetric comparison of bone marrow-sparing intensity-modulated radiotherapy versus conventional techniques for treatment of cervical cancer. Int J Radiat Oncol Biol Phys 71:1504–1510CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2018

Authors and Affiliations

  1. 1.Department of RadiotherapyUZ Brussel, Vrije Universiteit BrusselBrusselBelgium

Personalised recommendations