馬偕紀念醫院新竹分院 直腸癌放射治療指引 修訂 四版

Transcription

1 馬偕紀念醫院新竹分院 直腸癌放射治療指引 修訂 四版

2 前言 新竹馬偕醫院放射腫瘤科藉由跨院聯合會議機制進行討論, 以制定符合現狀之 直腸癌放射治療指引 本院直腸癌放射治療指引的建立, 係參考國內外文獻報告及台北總院臨床指引, 彙整而成 本院直腸癌分期採用美國 TNM 7 th edition 癌症分期系統, 符合臨床的需求 本院直腸癌放射治療流程, 以實證醫學方式並參考國內外醫學中心治療指引, 彙集而成 直腸癌放射治療指引 的目的, 為提供醫師在臨床處理之建議 醫師應秉其專業, 解釋治療之損益, 更要以病人及家屬的意願與選擇為主, 讓病人獲得最恰當的治療

3 Staging: AJCC 7 th edition (2010) Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: intraepithelial or invasion of lamina propria T1 Tumor invades submucosa T2 Tumor invades muscularis propria T3 Tumor invades through the muscularis propria into the pericolorectal tissues T4a Tumor pentrates to the surface of the visceral peritoneum T4b Tumor directly invades or is adherent to other organ of structures

4 Regional Lymph Nodes (N) (at least 10~14 nodes dissection) NX Regional lymph nodes cannot be assessed N0 No regional lymph nodemetastasis N1 Metastasis in 1~3 regional lymph nodes N1a Metastasisi in 1 regional lymph node N1b Metastasis in 2~3 regional lymph nodes N1c Tumor deposits in the subserosa, mesentery or nonperitonealized pericolic or perirectal tissues without regional node metatstasis. N2 Metastasis in 4 or more regional lympho nodes N2a Metastasis in 4~6 regional lymph nodes N2b Metastasis in 7 or more regional lymph nodes Distant Metastasis (M) MX Metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis M1a Metastasis confined to one organ or site (eg. liver, lung, ovary, nonregional node) M1b Metastasis in more than one organ/site or the peritoneum

5 Rectal cancer Radiotherapy recommendation Neoadjuvant radiotherapy ct3n0 or ct1-3n1~2 Neoadjuvant chemoradiotherapy plus surgery. ct4 and unresectable Neoadjuvant chemoradiotherapy 1. Resetable + adjuvant chemotherapy 2. Unresectable => systemic chemotherapy Resectable M1 Neoadjuvant chemoradiotherapy => synchronous resection => systemic chemotherapy Adjuvant radiotherapy pt3-4 or N+ adjuvant chemoradiotherapy + chemotherapy Resectable M1 1. Chemotherapy => synchronous resection => adjuvant chemoradiotherapy 2. synchronous resection => adjuvant chemoradiotherapy + chemotherapy. inoperable M1 Symtomatic 1. Combination systemic chemotherapy 2. Palliative 5-FU/RT or capecitabine/rt (2B) or UFUR+LV/RT, then advanced chemotherapy 3. Palliative surgery advanced chemotherapy Asymptomatic advanced chemotherapy determine respectability

6 Recurrence Isolated pelvic/anastomotic recurrence 1) Resectable op then C/T + RT; or pre-op CCRT then op +/- IORT 2) Unresectable C/T +/- RT Resectable metachronous metastases 1) No previous C/T op then postoperative CCRT or Neoadjuvant C/T then op 2) Previous C/T op then advanced chemotherapy or Neoadjuvant C/T then op, if no progression then repeat neoadjuvant C/T or FOLFOX; if progression then AC or OBS Unresectable metachronous metastases or post C/T with SD or PD 1) advanced chemotherapy 2) Regorafenib(Kras mutant only) 3) Clinical trial 4) Best supportive care Radiation Dose Definitive CTV1 = 50-60Gy CTV2 = 50Gy Preoperative CTV1 = 45 Gy (TCOG 45Gy then local boost 5.4Gy for T4 or perirectal LAP) CTV2 = 45Gy Postoperative CTV1 = 50-54Gy CTV2 = 50Gy

7 Radiotherapy delineation CTV1 1) Tumor bed. 2) Mesorectum 3) Anastomosis with sup. And inf. 5 cm margin CTV2 1) peri-rectal, pre-sacral, internal iliac nodal regions 2) external iliac nodal region in T4 stage. 3) Inguinal nodal region in anus invasion. Patient Set-up for rectal/anal cancers CT simulation A custom immobilization device Arms up position Supine or prone Bowel compression if prone Full bladder (intake 500cc of water within 40min) Oral and IV contrast Anal marker <=5mm slices (3mm at MMH) Multiple fields References: 1) RTOG ) ASTRO 2008 (colorectal and anal cancer, EDU session)

8 Ref: 1. Add Collette L, Bosset JF, den Dulk M et al. Patients with curative resection of ct3-4 rectal cancer after preoperative radiotherapy or radiochemotherapy: does anybody benefit from adjuvant fluorouracil-based chemotherapy? A trial of the European Organisation for Research and Treatment of Cancer Radiation Oncology Group. J Clin Oncol Oct 1;25(28): Add Fisher B, Wolmark N, Rockette H et al. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01. J Natl Cancer Inst Mar 2;80(1): Bonnen M, Crane C, Vauthey JN, et al. Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. IJROBP 2004;60(4): Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 2006;93: Folkesson J, Birgisson H, Pahlman L, et al. Sweedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005;23: Gérard JP, Conroy T, Bonnetain F et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD J Clin Oncol Oct 1;24(28): Guillem JG, Diaz-Gonzalez JA, MInsky BD, et al. ct3n0 rectal cancer: potential overtreatment with preoperative chemoradiotherapy is warranted. J Clin Oncol 2008;26(3): Kapiteijn E, Marijnen CAM, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345: NSABP R-02 reference: Wolmark N, Wieand HS, Hyams DM et al. Randomized trial of postoperative adjuvant chemotherapy with or without radiotherapy for carcinoma of the rectum: National Surgical Adjuvant Breast and Bowel Project Protocol R-02. J Natl Cancer Inst Mar 1;92(5): O Connell MJ, Martenson JA, Wieand HS, et al. Improving adjuvant therapy for rectal cancer by combining protracted-infusion fluorouracil with radiation therapy after curative surgery. N Engl J Med 1994;331: Pahlman L, Glimelius B, et al. Improved survival with preoperative radiotherapy in resectable rectal cancer: Swedish Rectal Cancer Trial. N Engl J Med 1997;336: Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351: Sebag-Montefiore D, Stephens R, Monson J, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCICCTG C016): a multicentre, randomized trial. Lancet 2009;373: