exam 6 Treat TX

Contraindications for digestive system

Tumor size that exceeds the dose and FS contraints

Indication for RT treatment for digestive system

- Tumor bleeding

- Pain

- Blockage

- Tissue sparing, kidney and liver

Treatment options for digestive

IMRT/VMAT and 3D-CRT techniques (3D open field, 3D conformal static, 3D conformal arcs, AP/PA and oblique

Typical digestive fraction

15-30 fractions

Typical structures for alignment for abdomen

- Tumor

- Spine

- Aorta

- Kidney

Routes of spread Colorectal

- Lymphatics

- Hematogenous (live and lung)

- Direct extension

- Transperitoneal implantation at time of surgery

- Peritoneal seeding

Peritoneal seeding

Tumor extends into bowel wall onto peritoneal surface, cells shed into the abdominal cavity

Treatment options for colorectal CA

-Surgery (treatment of choice)

-chemo (5U)

-RT (definitive, pre-op, post-op, with chemo)

-IORT

-EBRT

Hemicoloectomy

Large bowel segment, adjacent lymph nodes, & immediate vascular supply

Low anterior resection (LAR)

Removal of tumor + margin & immediate adjacent lymph nodes

Abdomino perineal resection (APR)

CA in lower 3rd of rectum - need colostomy

When is RT used for rectal CA

Larger rectal tumors with T3 or N1-N2 stage disease

Post op RT for rectal cancer

- Provides histology and extent of tumor spread prior RT+chemo

- RT + chemo improves local control and survival rates

Pre-op RT Rectal CA

- provides sphincter preservation

- shrink tumor and allows the pt to have LAR rather than APR and avoid a colostomy

Disadvantage: lack of pathological staging

Advantage of Pre-op Rt rectal

- downstaging primary tumor

- increased radio sensitivity

-increase in local control of the disease

Definitive RT for rectal cancer

Palliative

Why will RT and 5U be used for rectal cancer

Relieve symptoms, decreasing tumor, progression and increasing overall survival

Small bowel should be less than

45Gy

Easier with pre-op RT

dose for rectal cancer

-4500cGy to tumor + regional LNs

-taken to 5000cGy to 5500cGy to primary tumor bed

- 180cGy/day in 6 to 6.5 weeks

Pre-op hypofractionation rectal

25Gy in 5fx, so to follow 1 week post RT

How much is it recommed to extended inferior margin for rectal cancer

3-5cm beyond grow tumor, or extent of dissection

Tx technique for rectal cancer

IMRT/VMAT (most common, 3D-CRT

Traditional: 4 field box

IORT dose + 45-50cGy EBRT dose =

75-59Gy total effective dose

Speical instructions for rectal cancer

Rectal marker, barium or gastrografin contrast 45 min prior, marker, full bladder (to move small bowel out of field)

why will prone position be used for rectal cancer

spare anterior structures (small bowel)

Most important limiting structure for Rectal cancer

Small Bowel

TD 5/5 and endpoint Bladder

65, symptomatic contracture, volume loss

TD 5/5 and endpoint for small bowel

45, Obstruction/Perforation

Large bowel TD 5/5 and endpoint

45, Obstruction/Perforation ulceration/ Fistula

Femoral Head and Neck TD 5/5 and endpoint

54, Necrosis

Acute side effects rectal cancer

- Diarrhea

- Abdominal cramps bloating

- Proctitis

- Bloody/mucus discharge

Chronic side effects rectal cancer

- Persistant diarrhea

- Increased bowel frequency

- Bladder atrophy

- Proctitis

Route of spread anal cancer

- Direct extension

- lymphatic: inguinal nodes

- Hematogenous: liver, lungs (less common)

Tx options for anal cancer

- Surgery

- RT: IMRT/VMAT, Chemo+RT (Standtard), definitive

- Chemo: 5FU

Dose anal

- 4500cGy to the pelvis and inguinal nodes

- followe dby 900 to 1400cGy delivered to the primary tumor to reduce to the small bowel

- total dose of 5400 to 5900 cGy

Treatment tech anal

VMAT/IMRT

Traditional: 3D-CRT (AP/PA + fields to inguinal nodes and boost bed)- not typically used

Special instruction for anal

Place marker on anal verge

inf tumor margin: 3cm distal to lowest extent of the tumor (identified by radiopaque marker)

Symptoms anal cancer

- Nausea

- Diarrhea

- Vomitting

- Perianal skin reaction

Route of spread esophagus - Longitudinal

- Lymphatics

- Direct extension

- Hematogenous distant mets: liver & lungs the most common

Most common tx modalities for Esophageal cancer

1. deifnitive chemoradiation

2. Neoadjuvant chemoradiation followed by surgery

Dose for esophageal cancer

Definitive RT: 60 to 65Gy

Pre-op + chemo/Rt: 41.4 to 0.4Gy

Defintive RT/Chemo: 50 to 50.4Gy, off cord at 45Gy

Divisions for staging esophagus

- Cervical

- Upper thoracic

- Middle thoracic

- Lower thoracic

TD 5/5 and endpoint for Heart

40, Pericarditis

TD 5/5 and endpoint for lungs

17, Pneumonitis

TD 5/5 and endpoint for Esophagus

55, Clinical stricture/ Perforation

TD 5/5 and endpoint for Spinal Cord

47, Myelitis/ Necrosis

Side effects of Esophagus

- Pain during swallowing

- Sensation of food stuck in esophagus

- Pnumonitis

- Percarditis

Division of pancreas

Head, body, and tail

Lymphatic spread for pancrease

- Superior and inferior pancreaticoduodneal

- Portal hepatis

- Suprapancreatic

- Adjacent periaortic nodes

Direct extension pancrease

Duodenum, common bile duct, stomach and colon

Hematogenous spread pancreas

Liver via portal vein

Treatment Pancreas

RT+chemo (standard)

Sx incorporated is resectable

Most common currative surgery for Pancrease

Whipple

Dose for pancrease

45-54 Gy, 180cGy/day/ w/reduction in field volume after 45Gy

SBRT dose pancrease

vary 25-33Gy in 3 to 5fractions or 45Gy in 3 fractions

Speacial instructions pancrease

injection of contrast for kidney localization, barium for location of stomach and duodenum

TD 5/5 and endpoint Liver

30, Liver failure

TD 5/5 and Endpoint Kidney

23, Nephritis

TD 5/5 and Endpoint Stomach

55, Ulceration/ Perforation

Side effects Pancrease

- Nausea

- Vomiting

- Diarrhea

- Stomatitis

- Leukopenia

Chronic: renal failure

Trigone

Triangular portion of the bladder formed by the openings of the uters and urethra orifice

Carcinoma of bladder routes of spread

Direct extension - muscle invasion

Lymphatic - primary lymph drainage is through external and interal iliac and presacral nodes

Hematogenous - Bone, liver and lung

Types of radiation with carcinoma bladder

EBRT and Brachytherapy

Speical instructions carcinoma bladder

Foley catherter with contrast to outline the posterior portion of the bladder

Intial course carcinoma bladder

Empty bladder to ensure adequate margin

Boost carsinoma bladder

Full bladder to reduce the amount of healthy bladder treated in higher boost dose

Dose EBRT Bladder

45-50 large field to include pelvic lymph nodes, 180 cGy/day, 5 to 5.5 week of tx - empty bladder

if chemo uis used 45Gy

Deifnitive EBRT dose bladder

Boost included, taken to 65-70Gy

- FUll bladder

Field design for bladder

CTV & GTV: imcldues total bladder and tumor volume, prostate, prostatic urethra, and pelvic lymph nodes

PTV: 2-3cm sup&inf, 1-2cm ant&post

- IGRT & Bladder filling utilized: 1.5cm sup&ant, 1cm inf & post

IMRT - standard

Beam arrangment for Bladder

4 field (AP/PA, lateral), with boots field

LNs included for Bladder

Perivesical, obturator, external iliac, and internal iliac lymph nodes

TD 5/5 and endpoint bladder

65, symptomatic contracture volume loss

TD 5/5 and endpoint rectum

65, Servere proctitis/ Necrosis/ Stenosis/ Fistula

Kidney and renal pelvis lymph drainage

Along the vessels in the renal hilum to Paraaortic and paracaval nodes

Ureter lymph drainage

- Renal hilar

- Abdominal Paraaortic

- Paravacal

- Common Iliac

- Internal or external iliac

Routes of spread Renal cell

- Local infiltration

- Direct extension

- Retrograde venous drainage

- Lymphatic drainage

- Hematogenous

Renal cell RT

- Definitive if surgically unresectable tumors (palliative intent)

- Post op for psotive margins or incomplete resection

RT not recommended after complete resection

Dose for renal cell

4500-5500cGy (5040cGy msot common)

- 180cGy/fraction, 5 t0 6 weeks

boost: 540cGy in 3fx can be given (total dose to 5580cGy)

Field design Renal cell

post should include entire renal fossa, and site of gross recurrence, and paralytic nodal draining sites

Speical considerations renal cell

Limit remaining kidnet 1800cGy

Beam arrangment Renal Cell

AP/PA with shrinking field tehcniques to reduce dose to critical strucutres.

- SBRT alsho shown to be successful

Renal cell limiting structure

- Small Bowel (40 to 45Gy)

- Remaining Kidney (18Gy)

- Liver (30Gy, if right kidney)

- SPinal cord (45 to 47Gy)

Routes of spread prostate

- Local invasion

- Lymphatics

- Hematogenous

2 different delivery types for proton therapy

1. passive scattering (RT/LT lat with brass aoeratures to shape beam)

2. Penicl beam (IMRT PBT)

Transrectal ultrasound

used to irect the needle insertion that will deposit permanent radioactive seeds

Dose for implant alone (no EBRT) prostate

160Gy to prostate + margin

How far apart are seeds distributed for prostate LDR Brachytherapy

1cm apart

EBRT + interstitaial implant boost Prostate

45Gy to prostate, seminal vesicles, and maybe pelvic nodes

Intersitial LDR boost pancrease

90Gy w/Pd-103 or 110Gy 1/I-125

2 to 4 weeks post EBRT

HDR Prostate

Iridium - 192

Temporary implant

BID for 7 fx over 3.5 days, 6.5Gy/fx for total dose of 45.5Gy

Standard Fx dose Prostate

76Gy in 38fx, 200cGy/fx, 78Gy w/IGRT

HypoFx Dose Prostate

70Gy in 28fx, 250cGy/fx

traditional Beam arrangment prostate

4 field box technique - AP/PA, RT/LT Lats

- Field size of 15 x 15 followed by a reduced field of usually 8cm or 10cm

Conformal/IMRT Prostate

5 to 6 fields oblique fields

VMAT & Tomotherapy prostate

can further spare healthy tissues in prostate treatment

SBRT Prostate

GTV: 45Gy to GTV in 5fx, QOD

Prostate side effects Possible types

- Diarrhea

- Abdominal cramping

- Rectal bleeding

late effects prostate cancer

- Rectal bleeding

- Sexual impotence

- Ulceration

Penis and Male urethra treatment options

RT - EBRT, Brachytherapy

Surgery - local excision, partial or total penectomy

Chemo - Only advanced stages

Pallative dose penis and male urethra

20Gy, 5fx

30Gy, 10fx