Hyperfractionated accelerated reirradiation for rectal cancer: An analysis of outcomes and toxicity

Tao, Randa; Tsai, C. Jillian; Jensen, G.L.; Eng, Cathy; Kopetz, Scott; Overman, Michael J.; Skibber, John M.; Rodrı́guez-Bigas, Miguel A.; Chang, George J.; You, Yi Qian Nancy; Bednarski, Brian Keith; Minsky, Bruce D.; Delclos, Marc E.; Koay, Eugene J.; Krishnan, Sunil; Crane, Christopher H.; Das, Prajnan

doi:10.1016/j.radonc.2016.12.015

Cited by 48 publications

(53 citation statements)

References 26 publications

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“…We have previously advocated for the use of limited RT fields (tumor + 2-3 cm margin) for reirradiation in the setting of recurrent rectal cancer. 19 , 20 However, in the current series, 8 of 10 patients were given reirradiation to an elective nodal volume in addition to the primary tumor. Our rationale was that primary rectal cancer after other malignancies is a very different clinical entity compared with recurrent rectal cancer and the pattern of failure is likely to be locoregional for primary rectal cancer and local for recurrent rectal cancer.…”

Section: Discussionmentioning

confidence: 82%

“…In a recent study, we reported a 3-year FFLP rate of 40%, and a 3-year OS rate of 39% in 102 patients who were treated with reirradiation for recurrent rectal cancer. 20 However, the rates of FFLP and freedom from any progression appear to be lower than those typically expected for de novo rectal cancer. Inferences are difficult to draw from a small series such as this, but our results do raise the question of whether rectal cancer in the setting of prior pelvic radiation carries a worse prognosis.…”

Section: Discussionmentioning

confidence: 92%

“… 10 , 17 , 18 , 19 We recently published our long-term experience with a hyperfractionated accelerated regimen for the treatment of locally recurrent rectal cancer, and showed that reirradiation resulted in acceptable rates of toxicity along with promising rates of local pelvic control. 20 …”

Section: Introductionmentioning

confidence: 99%

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Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation

Jensen

Tao

Eng

et al. 2018

Advances in Radiation Oncology

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PurposePrevious studies have reported that hyperfractionated accelerated reirradiation can be used as part of multimodality treatment of locally recurrent rectal cancer with acceptable toxicity and promising outcomes. The purpose of this study was to evaluate the outcomes and toxicity of hyperfractionated accelerated reirradiation for patients with primary rectal adenocarcinoma and a history of prior pelvic radiation for other primary malignancies.Methods and materialsWe identified 10 patients with a prior history of pelvic radiation for other primary malignancies who were treated with hyperfractionated accelerated reirradiation for primary rectal adenocarcinoma. Radiation therapy was administered with 1.5 Gy twice daily fractions to a total dose of 39 Gy to 45Gy.ResultsThe median follow-up time was 3.2 years (range, 0.6-9.0 years). Seven of 10 patients received surgery after reirradiation. The 3-year freedom-from-local-progression rate was 62% for all patients and 80% for patients who underwent surgery. The 3-year overall survival rate was 100%, with 3 deaths occurring at 4.7, 6.5, and 9.0 years after reirradiation. One patient had an acute Grade 3 toxicity of diarrhea, and 1 patient experienced a late Grade 3 toxicity of sacral insufficiency fracture.ConclusionsHyperfractionated accelerated reirradiation was well tolerated with promising rates of freedom from local progression and overall survival in patients with primary rectal cancer with a history of prior pelvic radiation therapy. This approach, along with concurrent chemotherapy and surgery, appears to be a viable treatment strategy for this patient population.

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Section: Discussionmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 92%

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Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation

Jensen

Tao

Eng

et al. 2018

Advances in Radiation Oncology

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“…Advancements in radiotherapy have allowed conformal radiation dose distribution with delivery of incremental doses to tumors and a minimal dose to adjacent critical structures. Re-irradiation has shown satisfactory clinical outcome in certain recurrent tumors such as lung cancer, head and neck cancer, high-grade glioma, and rectal cancer [ 6 – 11 ]. In the present study, we evaluated the clinical prognostic factors associated with overall survival (OS) in recurrent ESCC.…”

Section: Introductionmentioning

confidence: 99%

Survival benefit of re-irradiation in esophageal Cancer patients with Locoregional recurrence: a propensity score-matched analysis

et al. 2018

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BackgroundTo investigate the treatment failure pattern and factors influencing locoregional recurrence of esophageal squamous cell carcinoma (ESCC) and examine patient survival with re-irradiation (re-RT) after primary radiotherapy.MethodsWe retrospectively analyzed 87 ESCC patients treated initially with radiotherapy. Failure patterns were classified into regional lymph node recurrence only (LN) and primary failure with/without regional lymph node recurrence (PF). Patients received either re-RT or other treatments (non-re-RT group). Baseline covariates were balanced by a propensity score model. Overall survival (OS) and toxicities were assessed as outcomes.ResultsThe median follow-up time was 87 months. Thirty-nine patients received re-RT. Failure pattern and re-RT were independent prognostic factors for OS (P = 0.040 and 0.015) by Cox multivariate analysis. Re-RT with concomitant chemotherapy showed no survival benefit over re-RT alone (P = 0.70). No differences in characteristics were found between the groups by Chi-square tests after propensity score matching. The Cox model showed that failure pattern and re-RT were prognostic factors with hazard ratios (HR) of 0.319 (P = 0.025) and 0.375 (P = 0.002), respectively, in the matched cohort. Significant differences in OS were observed according to failure pattern (P = 0.004) and re-RT (P < 0.001). In the re-RT and non-re-RT groups, 9.09% and 3.03% of patients experienced tracheoesophageal fistulas, and 15.15% and 3.03% of patients developed pericardial/pleural effusion, respectively (P > 0.05). The incidence of radiation pneumonitis was higher in the re-RT group (24.24% vs. 6.06%, P = 0.039), but no cases of pneumonia-related death occurred.ConclusionsRe-RT improved long-term survival in patients with locoregional recurrent ESCC. Despite a high incidence of radiation pneumonitis, toxicities were tolerable.

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“…There is currently no established standard for re-irradiation of recurrent rectal cancer much due to the lack of knowledge about late morbidity after radiotherapy, although hyper-fractionated RT has been shown to be feasible [19][20][21][22][23]. Most previous studies have been conducted with older techniques such as two lateral opposing fields, 3-field techniques, or 3D conformal radiotherapy [19][20][21]24,25]. However, CBCT-guidance allows for smaller margins and may in combination with the conformity of IMRT and VMAT significantly limit normal tissue dose.…”

Section: Discussionmentioning

confidence: 99%

The normal tissue sparing potential of an adaptive plan selection strategy for re-irradiation of recurrent rectal cancer

Byskov

Nyvang

Guren

et al. 2017

Physics and Imaging in Radiation Oncology

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Background and purpose: Radiotherapy (RT) of rectal cancer is challenged by potentially large interfractional anatomy changes. The risk of radiation-induced morbidity is a particular concern in patients receiving re-irradiation for recurrent disease. We propose an adaptive RT plan selection strategy for these patients and report on its clinical feasibility and normal tissue sparing potential. Material and methods: Eight patients with pelvic recurrence were re-irradiated according to a hyperfractionation protocol (ReRAD-I; 40.8 Gy) using margins around the clinical target volume (CTV) of 15 mm trimmed to anatomical barriers (Plan L). Two new library plans (S and M) were created for each patient, with the target volumes covering the CTV with isotropic margins of 5 and 10 mm. Pre-treatment cone beam CTs were assessed to determine which plan would cover the CTV following soft-tissue match. The selected plans were compared to the clinically delivered plan in terms of normal tissue volume receiving 95% of the dose (V95%) and the volume of bone receiving 30 Gy (V30 Gy). Results: Plan selections could be performed on all CBCTs for all patients. Plan S was chosen in 213 fractions (79%), plan M in 53 (20%) and plan L in 2 fractions. Normal tissue V95% was reduced by 67% (median; range 30-79%) while bone V30 Gy was reduced by 66% (median; range 40-100%). Conclusion: The CTV and/or surrogate structures were visible on all CBCTs. Margins smaller than those used clinically would have accounted for 99% of the observed target deformations, translating into a considerable normal tissue sparing potential.

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Hyperfractionated accelerated reirradiation for rectal cancer: An analysis of outcomes and toxicity

Cited by 48 publications

References 26 publications

Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation

Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation

Survival benefit of re-irradiation in esophageal Cancer patients with Locoregional recurrence: a propensity score-matched analysis

The normal tissue sparing potential of an adaptive plan selection strategy for re-irradiation of recurrent rectal cancer

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