Image-guided intensity-modulated radiotherapy for patients with locally advanced gastric cancer: a clinical feasibility study

Abstract

Background The aim of this study was to determine the medical and technical feasibility of intensity-modulated radiotherapy (IMRT) in high-risk nonmetastatic gastric cancer stage II and III after primary gastrectomy and D2 lymphadenectomy. Methods and materials A prospective nonrandomized phase II trial was performed on 25 consecutive patients with gastric cancer with high risk (T3-4, N1-3, G2-3, R0-1). The dose delivered was 45 Gy (1.80 Gy per fraction) in IMRT technique. Concurrent 5-fluorouracil-based chemotherapy at 225 mg/m 2 was administered as a continuous intravenous infusion. Primary endpoints were acute gastrointestinal toxicity (CTC 4.0) and technical feasibility of IMRT in regard to dose planning and radiation delivery. Results Early acute events were defined as clinical and chemical adverse effects of IMRT and concurrent chemotherapy during treatment. By definition, 90 days after the end of IMRT has been evaluated as acute-phase toxicity. No patient had grade 4 or higher acute adverse events. Clinical grade 3 toxicity occurred in two patients (8 %) with diarrhea and in one case (4 %) with nausea. Hematological changes with grade 3 occurred in three cases (12 %) with hemoglobin decrease, in five cases (25 %) as leukopenia, and in one case (4 %) with thrombocytopenia. The mean dose for liver was 16 Gy and the percentage volume exceeding 30 Gy (V30) was 21 %. Mean dose for right and left kidney was 9 and 13 Gy, respectively, and V20 was 9 % and 13 %, respectively. Heart received a median dose of 15 Gy and V40 was 17 %. The mean dose to the bowel was 11 Gy and V40 was 6 %. Spinal cord had at maximum 33 Gy in median. Specifics of dose distribution, including the coverage, for the target region were as follows: minimum was 33 Gy, maximum 48.6 Gy, and mean dose 44.6 Gy. The prescribed dose (45 Gy) covered 99 % and 95 % of planning target volume (OTV) in 66 % and 92 % of cases, respectively. Median PTV was 15.77 ml (range, 805-3,604 ml). Conclusions The data support the practical feasibility of IMRT in adjuvant treatment in high-risk gastric cancer in the postoperative setting as a proof of principle. Acute toxicity has been tolerable.

A retrospective study on intensity-modulated radiation therapy combined with chemotherapy after D2 radical surgery for gastric carcinoma

“…In our study, we used 5/7-field IMRT, with an incidence of grade 3 hematological toxicities during treatment of 23.5%; grade 3 gastrointestinal reactions of 13.7%; grade 1-2 liver and kidney function impairment of 9.8%; and grade 3 liver and kidney function impairment of 0%; these findings were similar to the results reported by Badakhshi et al (24). In addition, we observed that grade 3 hematological toxicities and gastrointestinal reactions mostly occurred due to the cumulative effect of subsequent adjuvant chemotherapy, and the toxic effects were usually grade 1-2 during concurrent CRT.…”

“…Moreover, IMRT also improved the postoperative gastric cancer treatment. Badakhshi et al (24) investigated 25 cases of patients who received concurrent CRT with IMRT after gastric cancer surgery, and observed that the incidences of grade 3 nausea and diarrhea during treatment were 4 and 8%, respectively, and the incidences of grade 3 decrease in hemoglobin level, leukocyte and platelet counts were 12, 25 and 4%, respectively.…”

Hitting a Moving Target: Successful Management of Diffuse Large B-cell Lymphoma Involving the Mesentery With Volumetric Image-guided Intensity Modulated Radiation Therapy

“…IMRT allows physicians to target the tumor while sparing nearby organs at risk, simultaneously reducing toxicity as well as improving coverage of the target volume. Previous studies have exhibited IMRT to be feasible in treating gastric cancer [39, 40], and in fact have also demonstrated a reduction in toxicity with this approach [41]. However, the use of IMRT for a moving target is yet another obstacle.…”

The cardiac toxicity of radiotherapy – a review of characteristics, mechanisms, diagnosis, and prevention

“…And VMAT can minimize heart damage, which presages the possible use of VMAT to patients with cardiac comorbidities (Campbell et al 2012). Data from several studies suggest that IMRT can reduce mean heart dose and cardiac adverse events for patients with breast cancer, NSCLC, and gastric carcinoma (Maraldo et al 2013;Badakhshi et al 2014;Sakka et al 2017;Jagsi et al 2018). IMRT impacted by multiple criteria optimization (MCO) can reduce the mean heart dose, with the presupposition of insuring treatment effectively.…”