diagnosing and treating cancer of the colon and rectum and using image guided IMRT radiation to treat
- 1. Cancer of the colon and rectum
- Understanding the disease
- Side effects of treatment
2. Colon and rectal stage is based on deep penetration and lymph nodes 3. 4.
- B. T categories. The patterns of spread and the primary tumor classification are similarly color coded:
- Tis (cancer in situ of mucosa), yellow;
- T1 (infiltrates the submucosa), green;
- T2 (penetrates the muscularis externa), blue;
- T3 (reaches the subserosa), purple; and
- T4 (invades through the serosa into a neighboring viscera), red.
5. Radiation can safely expand the surgical resection volume 6. 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 . 7. 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. 8. 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. 9. Normal male anatomy 10. 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. 11. 12. 13. Rectal Cancer and Nodes Sentinel nodes of the rectum include the pelvic perirectal and sacral nodes. 14. Lymph Nodes from Colon and Rectum 15. 16. Pelvic CT Anatomy Prostate rectum bladder 17. Bladder Prostate Rectum Pelvic CT Anatomy in Man 18. PET scan showing rectal cancer 19. 20. 21. 22. CT scan is obtained at the time of simulation CT images are then imported into the treatment planning computer 23. In the simulation process the CT and PET scan images are used to create a computer plan 24. Computer generated images and the size of the radiation cloud around these structures 25. Using PET Scan to identify site of rectal cancer cancer rectum prostate pubic bone bladder small bowel 26. Computer generated images to match the PET scan 27. Original PET scan showing area of cancer Computer generated images with radiation 28. Imaging rectal cancer radiation fields Portal image (x-ray image showing the area of radiation (light blue) Computer generated radiation target (dark blue) 29. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment 30. PET scan images are used to target the areas that need radiation 31. PET scan images are used to target the areas that need radiation 32. Radiation dose clouds are tailored to the areas that are at risk 33. Side Effects of Pelvic Radiation Radiation fields Radiation may hit the small bowel causing some cramps, diarrhea and fatigue 34. Side Effects of Pelvic Radiation Radiation fields Radiation may hit the bladder and rectum causing urinary burning or frequency and rectal irritation 35. Techniques to minimize radiation side effects (hitting the small bowel) using the belly board 36. Palliative radiation may still be quite useful in cases where the cancer has already spread or recurred
37. Palliating Pelvic Relapses
- Pain response rates in 64 85% range
- One series complete relief was bleeding (100%) pain (65%) mass 24%
38. Case Study: Recurrent Colon Cancer with Unresectable Mesenteric Mass 39. Recurrent Mass surrounded by loops of normal bowel , so technically difficult to treat with conventional radiation cancer bowel bowel 40. 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) 41. Using image guided IMRT can better target the cancer and limit the dose to normal structures Radiation dose cloud Radiation dose cloud 42. Low Dose Radiation for Liver Metastases 43. Radiosurgery for Liver Mets with Cyberknife 44. Radiosurgery for Liver Mets 45. 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 lesionlocal 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. 46. Brain Mets and Radiation conventional whole brain radiation or radiosurgery(Cyberknife or Gamma knife) 47. Radiation prescription for # Diagnosis: # External radiation: #Internal radiation: #