Neoadjuvant Therapy- Personalised Radiation Treatment For Rectal Cancer
MediSurg Global Learning Portal. Sun Myint A. 09/04/14; 62469
Disclosure(s): None to declare
Prof. Arthur Sun Myint
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Learning Objectives
Abstract
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1. The role of radiotherapy and chemotherapy in the management of locally advanced rectal cancer.
2. Indications for radiotherapy
3. Types of brachytherapy
4. Indication for intra-operative brachytherapy
5. Description of how brachytherapy is carried out with examples
6. Ongoing clinical trials for advanced rectal cancer
2. Indications for radiotherapy
3. Types of brachytherapy
4. Indication for intra-operative brachytherapy
5. Description of how brachytherapy is carried out with examples
6. Ongoing clinical trials for advanced rectal cancer
The role of radiotherapy in locally advanced rectal cancer
Surgery is the standard of care for rectal cancer. TME is recommended for upper and mid rectal cancers. Abdomino-perineal resection (APR) is necessary for low rectal cancer. The role of pre-operative radiotherapy in operable rectal cancer is still controversial. There was evidence of improved local control in using pre-operative SCRT from three large randomised trials involving over 3000 patients treated in the last four decades. The latest of these trials, MRC CR07 trial had shown improved local control with pre-operative SCRT for operable rectal cancer resected even by the best surgical plane (mesorectal). Despite this compelling evidence, most MDTs in the UK do not offer SCRT for operable rectal cancer. However, there is unanimous consensus for the use of pre-operative chemo-radiotherapy for locally advanced rectal cancer when CRM is threatened or involved. This treatment approach is to down size the advanced tumour and in most instances it also down staged the tumour, as well. Post treatment MRI scan is now recommended as part of the assessment prior to surgical resection. However, regardless of the tumour response observed, the findings on MRI does not change the initial surgical approach planned by most surgeons before the start of treatment. The dilemma is how to manage a few who achieved a complete clinical response with no obvious tumour detected on the MRI or endoscopy. After the MDT, the consensus of opinion by the MDT is relayed and the treatment recommendations discussed with patient. In most instances, the patient will agree with the MDT decision. Shared decision making with the patient is important. However, if the patients disagree with the decision of MDT for what ever reason, the patient decision should be respected. Usually these are cases where permanent stoma is need for very low rectal cancers. The patient has the right to refuse treatment even to the extent of no further treatment. Good practice guide by GMC and NICE guidelines (2011) recommend alternative treatment options should be discussed in such cases without a personal bias. This include further radiotherapy boost to escalate the radiation dose with brachytherapy either contact x-ray brachytherapy or HDR intraluminal brachytherapy. If the post treatment MRI scan showed that the CRM is still involved, then IORT with intra operative contact x-ray brachytherapy or HDR brachytherapy should be considered.
Suitable patients should be offered ongoing clinical trials such as ARISTOTLE which randomise between standard chemoradiotherapy using oral capecitabine against doublet chemotherapy with irinotecan and capecitabine for CRM involved advanced rectal cancer. The OPERA trial randomised against standard CRT with addition of contact x-ray brachytherapy boost to evaluate the role of dose escalation in less advance rectal T2 and T3 cancers.
The role of radiotherapy in rectal cancer management is changing rapidly and we need keep abreast with these changes by regular CPD programmes in order to be aware of new innovative radiotherapy techniques which may help in the management of patients with rectal cancer.
Surgery is the standard of care for rectal cancer. TME is recommended for upper and mid rectal cancers. Abdomino-perineal resection (APR) is necessary for low rectal cancer. The role of pre-operative radiotherapy in operable rectal cancer is still controversial. There was evidence of improved local control in using pre-operative SCRT from three large randomised trials involving over 3000 patients treated in the last four decades. The latest of these trials, MRC CR07 trial had shown improved local control with pre-operative SCRT for operable rectal cancer resected even by the best surgical plane (mesorectal). Despite this compelling evidence, most MDTs in the UK do not offer SCRT for operable rectal cancer. However, there is unanimous consensus for the use of pre-operative chemo-radiotherapy for locally advanced rectal cancer when CRM is threatened or involved. This treatment approach is to down size the advanced tumour and in most instances it also down staged the tumour, as well. Post treatment MRI scan is now recommended as part of the assessment prior to surgical resection. However, regardless of the tumour response observed, the findings on MRI does not change the initial surgical approach planned by most surgeons before the start of treatment. The dilemma is how to manage a few who achieved a complete clinical response with no obvious tumour detected on the MRI or endoscopy. After the MDT, the consensus of opinion by the MDT is relayed and the treatment recommendations discussed with patient. In most instances, the patient will agree with the MDT decision. Shared decision making with the patient is important. However, if the patients disagree with the decision of MDT for what ever reason, the patient decision should be respected. Usually these are cases where permanent stoma is need for very low rectal cancers. The patient has the right to refuse treatment even to the extent of no further treatment. Good practice guide by GMC and NICE guidelines (2011) recommend alternative treatment options should be discussed in such cases without a personal bias. This include further radiotherapy boost to escalate the radiation dose with brachytherapy either contact x-ray brachytherapy or HDR intraluminal brachytherapy. If the post treatment MRI scan showed that the CRM is still involved, then IORT with intra operative contact x-ray brachytherapy or HDR brachytherapy should be considered.
Suitable patients should be offered ongoing clinical trials such as ARISTOTLE which randomise between standard chemoradiotherapy using oral capecitabine against doublet chemotherapy with irinotecan and capecitabine for CRM involved advanced rectal cancer. The OPERA trial randomised against standard CRT with addition of contact x-ray brachytherapy boost to evaluate the role of dose escalation in less advance rectal T2 and T3 cancers.
The role of radiotherapy in rectal cancer management is changing rapidly and we need keep abreast with these changes by regular CPD programmes in order to be aware of new innovative radiotherapy techniques which may help in the management of patients with rectal cancer.
The role of radiotherapy in locally advanced rectal cancer
Surgery is the standard of care for rectal cancer. TME is recommended for upper and mid rectal cancers. Abdomino-perineal resection (APR) is necessary for low rectal cancer. The role of pre-operative radiotherapy in operable rectal cancer is still controversial. There was evidence of improved local control in using pre-operative SCRT from three large randomised trials involving over 3000 patients treated in the last four decades. The latest of these trials, MRC CR07 trial had shown improved local control with pre-operative SCRT for operable rectal cancer resected even by the best surgical plane (mesorectal). Despite this compelling evidence, most MDTs in the UK do not offer SCRT for operable rectal cancer. However, there is unanimous consensus for the use of pre-operative chemo-radiotherapy for locally advanced rectal cancer when CRM is threatened or involved. This treatment approach is to down size the advanced tumour and in most instances it also down staged the tumour, as well. Post treatment MRI scan is now recommended as part of the assessment prior to surgical resection. However, regardless of the tumour response observed, the findings on MRI does not change the initial surgical approach planned by most surgeons before the start of treatment. The dilemma is how to manage a few who achieved a complete clinical response with no obvious tumour detected on the MRI or endoscopy. After the MDT, the consensus of opinion by the MDT is relayed and the treatment recommendations discussed with patient. In most instances, the patient will agree with the MDT decision. Shared decision making with the patient is important. However, if the patients disagree with the decision of MDT for what ever reason, the patient decision should be respected. Usually these are cases where permanent stoma is need for very low rectal cancers. The patient has the right to refuse treatment even to the extent of no further treatment. Good practice guide by GMC and NICE guidelines (2011) recommend alternative treatment options should be discussed in such cases without a personal bias. This include further radiotherapy boost to escalate the radiation dose with brachytherapy either contact x-ray brachytherapy or HDR intraluminal brachytherapy. If the post treatment MRI scan showed that the CRM is still involved, then IORT with intra operative contact x-ray brachytherapy or HDR brachytherapy should be considered.
Suitable patients should be offered ongoing clinical trials such as ARISTOTLE which randomise between standard chemoradiotherapy using oral capecitabine against doublet chemotherapy with irinotecan and capecitabine for CRM involved advanced rectal cancer. The OPERA trial randomised against standard CRT with addition of contact x-ray brachytherapy boost to evaluate the role of dose escalation in less advance rectal T2 and T3 cancers.
The role of radiotherapy in rectal cancer management is changing rapidly and we need keep abreast with these changes by regular CPD programmes in order to be aware of new innovative radiotherapy techniques which may help in the management of patients with rectal cancer.
Surgery is the standard of care for rectal cancer. TME is recommended for upper and mid rectal cancers. Abdomino-perineal resection (APR) is necessary for low rectal cancer. The role of pre-operative radiotherapy in operable rectal cancer is still controversial. There was evidence of improved local control in using pre-operative SCRT from three large randomised trials involving over 3000 patients treated in the last four decades. The latest of these trials, MRC CR07 trial had shown improved local control with pre-operative SCRT for operable rectal cancer resected even by the best surgical plane (mesorectal). Despite this compelling evidence, most MDTs in the UK do not offer SCRT for operable rectal cancer. However, there is unanimous consensus for the use of pre-operative chemo-radiotherapy for locally advanced rectal cancer when CRM is threatened or involved. This treatment approach is to down size the advanced tumour and in most instances it also down staged the tumour, as well. Post treatment MRI scan is now recommended as part of the assessment prior to surgical resection. However, regardless of the tumour response observed, the findings on MRI does not change the initial surgical approach planned by most surgeons before the start of treatment. The dilemma is how to manage a few who achieved a complete clinical response with no obvious tumour detected on the MRI or endoscopy. After the MDT, the consensus of opinion by the MDT is relayed and the treatment recommendations discussed with patient. In most instances, the patient will agree with the MDT decision. Shared decision making with the patient is important. However, if the patients disagree with the decision of MDT for what ever reason, the patient decision should be respected. Usually these are cases where permanent stoma is need for very low rectal cancers. The patient has the right to refuse treatment even to the extent of no further treatment. Good practice guide by GMC and NICE guidelines (2011) recommend alternative treatment options should be discussed in such cases without a personal bias. This include further radiotherapy boost to escalate the radiation dose with brachytherapy either contact x-ray brachytherapy or HDR intraluminal brachytherapy. If the post treatment MRI scan showed that the CRM is still involved, then IORT with intra operative contact x-ray brachytherapy or HDR brachytherapy should be considered.
Suitable patients should be offered ongoing clinical trials such as ARISTOTLE which randomise between standard chemoradiotherapy using oral capecitabine against doublet chemotherapy with irinotecan and capecitabine for CRM involved advanced rectal cancer. The OPERA trial randomised against standard CRT with addition of contact x-ray brachytherapy boost to evaluate the role of dose escalation in less advance rectal T2 and T3 cancers.
The role of radiotherapy in rectal cancer management is changing rapidly and we need keep abreast with these changes by regular CPD programmes in order to be aware of new innovative radiotherapy techniques which may help in the management of patients with rectal cancer.
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