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Protocol of Radiotherapy for Rectal Cancer

Indication of radiotherapy
Indication of neoadjuvant CCRT
(1) cStage II, III
(2) Lower rectum cStage I disease for organ preservation. (RT +/- C/T) (option)
Indication of adjuvant CCRT
(1) pStage,
(2) pT1 by local excision with high risk factors (if patient denied re-operation)

Simulation and Treatment Planning
Use of CT simulation and 3D/IMRT/VMAT treatment planning is required to
ensure adequate target volume coverage and avoid normal tissue irradiation.
When clinically appropriate, use of IV and/or oral contrast for CT simulation may
be used to aid in target localization.
Use of an immobilization device (such as vacuum cushion or ankle holder) is
strongly recommended for reproducibility of daily set-up.
Patients could be simulated and treated either in the supine or prone position.
Positioning and other techniques to minimize the volume of small bowel in the
field should be encouraged.
Full bladder filling is not compulsorily necessary (Drzymala et al., 2009).


Radiation Treatment Fields (CTV)
Radiation therapy fields should include the tumor or tumor bed and mesorectum
with an adequate margin, the pre-sacral nodes, and the internal iliac nodes.
The external iliac nodes should also be included for T4 tumors involving anterior
structures.
The inguinal nodes should also be included for lower tumors involving the anal
canal or the anal margin or advanced disease with lower third vaginal involvement.
Pelvic nodal CTV contours : 7mm around vessels, carving out bowel, bladder and
bone. (based by RTOG consensus)
The ischial fossa should be included RT field if tumor invasion to this area.
For postoperative patients treated by abdominoperineal resection, the perineal
wound should be included within the fields.
Different CTV to create PTV margin should be considered for motion target
(rectum) and motionless target (pelvis nodal) ( 5~20 mm), but if IGRT used ,the
margin could be reduced.



Radiation dose
Once daily, 5-6 fractions per week.
For resectable cancers, after 45 Gy to pelvis, a tumor bed boost with an adequate
margin of 5.4 Gy in 3 fractions could be considered for preoperative radiation (for
T4 disease, total dose 54Gy may be considered) and 5.4-9.0 Gy in 3-5 fractions for
postoperative radiation.
For patients with very close or positive margins after resection, especially for
patients with T4 or recurrent cancers, as an additional boost, 10-20 Gy external
beam radiation (IMRT) to a limited volume could be considered soon after surgery,
prior to adjuvant chemotherapy.
For unresectable cancers, doses higher than 54 Gy may be required, if technically
feasible.


Constraints of OAR
References: RTOG 0822 ( IMRT Planning Constraints)

Small bowel:
No more than 180 cc above 35 Gy
No more than 100 cc above 40 Gy
No more than 65 cc above 45 Gy
No small bowel volume should receive 50 Gy
Femoral heads:
No more than 40% volume above 40 Gy
No more than 25% volume above 45 Gy
No femoral head volume should receive 50 Gy
Bladder:
No more than 40% volume above 40 Gy
No more than 15% volume above 45 Gy
No bladder volume should receive 50 Gy
Unspecified Tissue:
No specific constraints, however a DVH will be generated for
unspecified tissue which consists of any tissue within the skin but not
contoured as a part of any of the normal structures above and/or the PTV.



References
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