Cancer of the colon and rectum

Understanding the disease Treatment options Side effects of treatment

Colon and rectal stage is based on deep penetration and lymph nodes

Rectal Cancer

A. Patterns of spread.

B. B. T categories. The patterns of spread and the primary tumor classification are similarly color coded:

C. Tis (cancer in situ of mucosa), yellow;

D. T1 (infiltrates the submucosa), green; \

E. T2 (penetrates the muscularis externa), blue;

F. T3 (reaches the subserosa), purple; and

G. T4 (invades through the serosa into a neighboring viscera), red.

Radiation can safely expand the ‘surgical resection’ volume

Rectal cancers can be resected as Stage II A/B (purple) with N1 nodes but are less favorable and borderline resectable stage IIIC (red) as N2 nodes (>4) are found, stage IV are (black) metastatic. Stage 0, yellow; I, green; II, blue; III, purple; IV, red; and IV (metastatic), black. Definitions of TN on

left and stage grouping on right.

A. Coronal. B. Sagittal (left, male; right, female). C. Transverse (left, male; right, female). (1) Right ureter. (2) Rectum. (3) External anal sphincter. (4) Middle rectal artery. (5) Left external iliac artery. (6) Roof of sigmoid mesocolon. (7) Urinary bladder. (8) Prostate. (9) Rectovesical pouch. (10) Seminal vesicle. (11) Levator ani. (12) Anal canal. (13) Internal anal sphincter. (14) Uterus. (15) Vesicouterine pouch. (16) Urethra. (17) Cervix of uterus. (18) Rectouterine pouch (of Douglas). (19) Obturator internus. (20) Prostatic venous plexus. (21) Ovary.

Male Anatomy

(2) Rectum. (3) External anal sphincter. (4) Middle rectal artery. (5) Left external iliac artery. (6) Roof of sigmoid mesocolon. (7) Urinary bladder. (8) Prostate.(10) Seminal vesicle. (11) Levator ani. (12) Anal canal. (13) Internal anal sphincter. (16) Urethra. (17) Cervix of uterus. ( (19) Obturator internus. (20) Prostatic venous plexus.

Normal male anatomy

Female Anatomy

(2) Rectum. (7) Urinary bladder. (9) Rectovesical pouch. (11) Levator ani. (12) Anal canal. (13) Internal anal sphincter. (14) Uterus. (15) Vesicouterine pouch. (16) Urethra. (17) Cervix of uterus. (18) Rectouterine pouch (of Douglas). (19) Obturator internus. (21) Ovary.

Rectal Cancer and Nodes

Sentinel nodes of the rectum include the pelvic perirectal and sacral nodes.

Lymph Nodes from Colon and Rectum

Pelvic CT Anatomy

Prostate

rectum

bladder

Bladder

Prostate

Rectum

Pelvic CT Anatomy in Man

PET scan showing rectal cancer

CT scan is obtained at the time of simulation

CT images are then imported into the treatment planning computer

In the simulation process the CT and PET scan images are used to create a computer plan

Computer generated images and the size of the radiation cloud around these structures

Using PET Scan to identify site of rectal cancer

cancer

rectumprostate pubic bone

bladder

small bowel

Computer generated images to match the PET scan

Original PET scan showing area of cancer

Computer generated images with radiation

Imaging rectal cancer radiation fields

Portal image (x-ray image showing the area of radiation (light blue)

Computer generated radiation target (dark blue)

In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment

PET scan images are used to target the areas that need radiation

PET scan images are used to target the areas that need radiation

Radiation dose clouds are tailored to the areas that are at risk

Side Effects of Pelvic Radiation

Radiation fields

Radiation may hit the small bowel causing some cramps, diarrhea and fatigue

Side Effects of Pelvic Radiation

Radiation fields

Radiation may hit the bladder and rectum causing urinary burning or frequency and rectal irritation

Techniques to minimize radiation side effects (hitting the small bowel) using the “belly board”

Palliative radiation may still be quite useful in cases Palliative radiation may still be quite useful in cases where the cancer has already spread or recurredwhere the cancer has already spread or recurred

Local pelvic relapsesLocal pelvic relapses Liver metastasesLiver metastases Distant metastasesDistant metastases

Palliating Pelvic RelapsesPalliating Pelvic Relapses

Pain response rates in 64 – 85% Pain response rates in 64 – 85% rangerange

One series complete relief was One series complete relief was bleeding (100%) pain (65%) mass bleeding (100%) pain (65%) mass 24%24%

Case Study: Recurrent Colon Cancer with Unresectable Mesenteric Mass

Recurrent Mass surrounded by loops of normal bowel , so technically difficult to treat with conventional radiation

cancer

bowel

bowel

Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

Using image guided IMRT can better target the cancer and limit the dose to normal structures

Radiation dose cloud

Radiation dose cloud

Low Dose Radiation for Liver MetastasesLow Dose Radiation for Liver Metastases

Radiosurgery for Liver Mets with CyberknifeRadiosurgery for Liver Mets with Cyberknife

Radiosurgery for Liver MetsRadiosurgery for Liver Mets

A phase I/II dose-escalation trial of Cyberknife radiation for control of primary or metastatic liver disease

Early toxicity has been mild with 3 patients (13%) experiencing grade 2 or greater toxicity. In the 21 patients with >3 month follow-up, 3 (14%) have experienced a late toxicity. There have been 6 local recurrences. The lesion local recurrence rate is 17% and the patient local recurrence rate is 25%. Mean time to recurrence was 8.4 months.

Conclusion: Cyberknife radiation can be delivered safely in doses up to 30 Gy in a single fraction. Accrual of long-term local control and toxicity data is ongoing.

Brain Mets and RadiationBrain Mets and Radiation conventional whole brain radiation or radiosurgery conventional whole brain radiation or radiosurgery

(Cyberknife or Gamma knife)(Cyberknife or Gamma knife)

Radiation prescription for #

Diagnosis: #

External radiation: #

Internal radiation: #