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KHOA XẠ TỔNG HỢP

5 5

7 8
5
 Surgery

Radiation therapy

Chemotherapy
Treatment

Targeted therapy

Immuno therapy
Adjuvant:
 Neo adjuvant : T3+ or/and N+ Mx
 Adjuvant : T3+ or/and N+ M0

Palliative:
 Bleeding
 Block
 Pain
 Dosing schedules for concurrent chemotherapy/RT

 XRT + continuous infusion 5-Fu

 5-Fu 225 mg/m2 over 24 hour 5 or 7 days/week during XRT
 XRT + capecitabine
 Capecitabine 825 mg/m2 twice daily 5d/wk + XRT x 5weeks
 XRT + 5-Fu/leucovorin
 5-Fu 400mg/m2 IV bolus + leucovorin 20 mg/m2 IV bolus for 4
days during week 1 and 5 of XRT
General principles
 Fluoropyrimidine-base chemotherapy should be delivered
concurrently with radiation therapy
 In patients with a limited number of liver or lung metastases,
radiation to the metastatic site can be considered in highly selected
cases or in the setting of a clinical trial.
Taget volumes
 Radiation therapy fields should include the tumor or tumor bed,
with a 2 to 5 cm margin, the mesorectum, the presacral nodes, and
the internal iliac nodes. The external iliac nodes should also be
included for T4 tumor involving anterior structures
 For postoperative patients treated by abdominoperineal resection,
the perineal wound should be included within the fields.
AP, PA field
 superior : L5/S1 interspace;
 inferior: the inferior edge of the obturator foramen or 3 cm below
the GTV, whichever is more distal;
 Lateral:1.5–2 cm beyond the pelvic brim.
Lateral fields
 Superior. inferior.
 Anterior: posterior margin of the pubic symphysis for T3 or at least
1cm anterior to the anterior edge of the pubic symphysis for T4
 posterior: 1–1.5 cm posterior to the posterior edge of the bony
sacrum
Taget volumes

GTV : GTV-P+GTV-N
CTV-HR: GTV-P and GTV-N with 1.5–2-cm margin expansion
superiorly and inferiorly.
1–2-cm margin around gross tumor invasion into adjacent organs
should be added.
This volume should include the entire rectum,mesorectum, and
presacral,
CTV-SR : internal iliac, external iliac nodes, obturator nodes
Superiorly :up to L5/S1 .least 1-cm margin superior to the
anastomosis, whichever is most cephalad
Inferiorly : the pelvic floor or at least 2 cm below the gross disease.
perineal scar for abdominoperineal resection
PTV :CTV + 0.5–1 cm
RTOG anorectal contouring atlas.
CTV-A : perirectal, presacral, and internal iliac regions
CTV-B : the external iliac nodes (T4 or extend inferiorly into the
distal anal canal).
CTV-C : the inguinal region (extend into the distal anal canal)
RT Dosing

 45-50 Gy in 25-28 fraction to the pelvis

 For resectable cancer, after 45 Gy a tumor bed boost with a 2-cm

margin of 5,4 Gy in 3 fraction could be considered for preoperative
radiation and 5.4-9.0 in 3-5 fraction for postoperative radiation

 Short course radiation therapy(25 Gy in 5 fraction) with surgery

within 1 week of completion of therapy or delayed 6-8 weeks can
also be considered for patients with stage T3 rectal cancer

 For unresectable cancer, doses higher than 54 Gy may be required,if

technically feasible

 Small bowel dose should be limited to 45 Gy

Simulator TPS

Treatment QA-QC
1.Adjuvant therapy after sugery for rectal cancer
 the optimal sequence of adjuvant RT and chemotherapy has
not been established conclusively.
 In a non-study setting, we typically administer two months of
chemotherapy followed by six weeks of 5FU/RT and then by
two months of additional chemotherapy.
 However, an acceptable alternative is to start with four months
of chemotherapy and finish up with 5FU/RT.

 https://www.uptodate.com/contents/adjuvant-therapy-for-resected-rectal-adenocarcinoma-in-
patients-not-receiving-neoadjuvant-
therapy?fbclid=IwAR25BEmVkjh38aVZI2aSfBkYV1TxECykllGJB7ZBTUTVU6Hx-okfJFDu-
HY#H25
2.Role CRT for mCRC

Resectable

mCRC Potential Resectable

Unresectable
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200534/
 highly selected cases or in the setting of a clinical trial
 oligometastases from CRC : systemic chemotherapy(included
chemotherapy and targeted therapy with/without cetuximab),
targeted therapy, and local therapy including surgical resection,
RFA, and TAE/TACE before radiotherapy were allowed.
 chemotherapy regimens : FOLFOX, XELOX, FOLFIRI, Xeloda,
and S-1.
 Radiotherapy: 3D-CRT, IMRT, or SBRT
 The median OS and PFS were 30.0 months and 11.0 months in
patients with oligometastases.
3.Short course vs long course
 LR:Cumulative incidences of LR at 3 years were 7.5% for SC and
4.4% for LC
 Five-year incidence rates of distant recurrence were 27% and 30%
for SC and LC
 Pathologic downstaging was significantly more common in patients
randomly assigned to LC. In particular, 15% LC patients had a
pathologic complete response(ypT0) compared with 1% SC
patients
 The rates for G3-4, small or large intestine toxicity for SC and LC
were 3.2% and 5.1%, respectively

 https://www.ncbi.nlm.nih.gov/m/pubmed/23008301/?fbclid=IwAR3Wz_pSFibnS777CSeveX0MTkfxvK4
PgtBE230JC-dkIBcKhkOmzGSToQY