| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | AA | |
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1 | Site/Stage | Workup | Treatment | Sim | Dose | Field | Chemo | Dosimetry | Timing | Notes | F/u | Outcomes | Adverse effects | Citations (full in reference tab) | |||||||||||||
2 | GI | ||||||||||||||||||||||||||
3 | Anal margin T1 anal margin=area below anal verge to 5-6 cm out on skin. Keratinizing epithelium Anal verge=area near end of anus where nonkeratinizing epithelium becomes keratinizing epithelium (=NOT dentate line) | Workup same as anal cancer EUS/MRI to confirm resectability NCCN recommends local excision for T1 well diff as long as 1 cm margin can be obtained (typically less than 40% circumference and no sphincter involvment) | Post-op: if inadequate margins, re-excision preferred. If unresectable give RT +/- chemo After treatment: If mod/poor diff and negative margins, still T1: can give RT alone to 45 Gy to perianal and inguinals For positive margins, still T1: could give RT alone to 45 Gy to perianal/inguinals plus boost to 50.4 Gy to tumor For T2 or greater: give chemo in addition to RT. Treat perianal/inguinal field (per Steel, no chemo needed) | For T1-T2, cover perianal region and inguinals. For T3-4 or N+, add pelvis NCCN directs to fields same as anal canal Anal margin guidelines, Steele, Practice Patterns, 2012 | NCCN: Cape/MMC for T2 or greater Steele, Practice patterns, 2012: Cape/MMC for T3-T4 or N+ | NCCN. Anal Carcinoma. Steele et al, Practice Patterns, 2012 | |||||||||||||||||||||
4 | Anal margin T1, not operable | workup same as anal cancer | RT alone or with chemoRT | NCCN. Anal Carcinoma. | |||||||||||||||||||||||
5 | Anal margin >T1 | workup same as anal cancer | Treat as anal cancer per NCCN | NCCN. Anal Carcinoma. | |||||||||||||||||||||||
6 | Superficially invasive SCC (SISCCA) of anal canal or margin | found incidentally when performing biopsy or excision of condyloma, hemorrhoid, or anal skin tag | close observation is an option | NCCN. Anal Carcinoma. | |||||||||||||||||||||||
7 | Anal canal T1-T2N0 | 50.4/42 Gy in 28 fx (1.8/1.5 Gy per fx) 50.4 Gy to primary and 42 to elective nodes If treating after surgery for microscopic margins, treat to just 45 Gy | Consider diversion first, especially if abscess or incontinence supine, vac loc, oral contrast, full bladder, anal bead marker In female patients, some treat with vaginal dilator to help avoid vaginal fibrosis | IMRT SIB PTV elective: 42 Gy PTV gross: 50.4 Gy | GTV 50.4 = gross disease as determined by CT (and MRI or PET), DRE, endoscopy and biopsy. Contour GTV plus anal canal with a 2 cm CTV margin radially or 1-2mm beyond levator and at least 1 cm CTV added sup/inf. The entire mesorectum is included in the boost CTV 42 includes mesorectal (incl. presacral) (Guideline unclear on anterior border. Can include 1 cm into bladder), bilateral inguinal, ext, and int iliacs with 7mm margin (caudal inguinal border is 2cm from saphenous/femoral junction). PTV is an additional 1 cm of margin on these strucures | NCCN recommends chemo even for T1-T2. Some might avoid for T1 | RTOG 0529: Small bowel V25<185 cc, V30<155 cc, V35<40 cc, V40<30 cc femoral heads V44<5%, V40<35%, V30<50% iliac crests V50<5%, V40<35%, V30<50% ext genitalia V40<5%, V30<35%, V20<50% bladder V50<5%, V40<35%, V35<50% (small bowel constraints are from secondary analysis. See Olsen IJROBP 2017) | concurrent | DRE in 10 weeks, if persistent disease re-eval in 4 weeks if continues to regress, observation q3 mos if progressive, biopsy and proceed to APR if recurrent If CR evaluate with DRE, anoscopy and inguinal node exam q6 mo x 5 yr vaginal dilator | RTOG 9811 Ajani et al, JAMA, 2008 Gunderson, JCO, 2012 RTOG 0529 Kachnic et al, IJROBP, 2013 Olsen et al, IJROBP, 2017 NCCN. Anal Carcinoma. RT in periaortic mets Holliday et al, IJROBP, 2018 Vaginal dilator with sim Son et al, IJROBP, 2015 | |||||||||||||||||
8 | Anal T3/4N0 | H&P: LN eval, DRE, anal sphincter tone, sexual history, HIV, HPV, IBD history, Gyn exam. Family history Labs: CBC, HIV if risk factors Anoscopy/Proctoscopy/colonoscopy with bx. FNA of inguinal nodes. EUS. CT chest, CT/MRI of A/P. PET scan not required but can be ordered for treatment delineation | RTOG IMRT: 54/45 Gy SIB in 30 fx (1.8/1.5 daily) Consider increasing to 60 Gy if T4 RTOG 9811: 30.6 ---> 36 or 45 ---> 55-59 30.6 Gy: AP field to sup L5/S1, inf flash, lateral to greater trochanters. PA field is smaller, 2 cm lateral to greater sciatic notch. Ant electrons are matched with PA. After 30.6 Gy, the sup border is lowered to the inf border of the SI joints, and this is treated to +14.4 Gy = 45 Gy. If N0, stop after +6 Gy=36 Gy Then boost nodes and tumor +10-14 Gy=55-59 Gy | Consider diversion first, especially if abscess or incontinence supine, vac loc, oral contrast, full bladder, anal bead marker In female patients, some treat with vaginal dilator to help avoid vaginal fibrosis | IMRT SIB PTV elective: 45 Gy PTV gross: 54 Gy optional boost to 60 Gy | GTV 54 = gross disease as determined by CT (and MRI or PET), DRE, endoscopy and biopsy. Contour GTV plus anal canal with a 2 cm CTV margin radially or 1-2mm beyond levator and at least 1 cm CTV added sup/inf. The entire mesorectum is included in the boost CTV 45 includes mesorectal (incl. presacral) (Guideline unclear on anterior border. Can include 1 cm into bladder), bilateral inguinal, ext, and int iliacs with 7mm margin (caudal inguinal border is 2cm from saphenous/femoral junction). PTV is an additional 1 cm of margin on these strucures RTOG colorectal atlas, IJROBP, 2009 Australasian atlas, IJROBP, 2011 econtour.org | NCCN allows MMC and capacitabine 825 mg/m2 BID M-F. Can do MMC 10 mg/m2 on day 1 and 29 or only MMC 12 mg/m2 1 cycle on day 1 OR: concurrent 5FU + MMC CI 5FU 1000mg/m2 days x4 days, bolus MMC 10mg/m2 x 1 day, given day 1 and day 29. Can consider just doing 1 cycles MMC, especially if just doing 28 treatments of RT for early stage | DRE and vaginal dilator as above, also with CT imaging | RTOG 9811 5-yr OS 80%, 5-yr DFS 70%, CFS 12% ACT II CR 90% Best CR at 26 weeks 5yr OS 80/75/50/10 for stage I/II/III/IV (Stage I = T1N0, Stage II = T2,3N0, Stage III = T4 or node positive, Stage IV = mets) LC 95/75/55 for T1-3; Salvage APR success rate 50% Note that 5yr OS improved with RT and 5FU/MMC over 5FU/CDDP on 98-11, 78% vs 70% on update. Also better disease survival, lower colostomy rates (5yr 10%) | RTOG 9811 Ajani et al, JAMA, 2008 Gunderson, JCO, 2012 RTOG 0529 Kachnic et al, IJROBP, 2013 Olsen et al, IJROBP, 2017 NCCN. Anal Carcinoma. RT in periaortic mets Holliday et al, IJROBP, 2018 Vaginal dilator with sim Son et al, IJROBP, 2015 | |||||||||||||||||
9 | Anal N+ | 54/50.4/45 Gy in 30 fx (1.8/1.68/1.5 daily) 54 to primary and nodal regions with nodes>3 cm 50.4 to nodal regions with nodes<3 cm 45 to negative nodal regions If PA nodes are present, include these as well and treat definitively | Consider diversion first, especially if abscess or incontinence supine, vac loc, oral contrast, full bladder, anal bead marker In female patients, some treat with vaginal dilator to help avoid vaginal fibrosis | IMRT SIB PTV elective: 45 Gy PTV N+ < 3 cm: 50.4 Gy PTVprim, N+ >3 cm: 54 Gy | NCCN allows MMC and capacitabine 825 mg/m2 BID M-F. Can do MMC 10 mg/m2 on day 1 and 29 or only MMC 12 mg/m2 1 cycle on day 1 OR: concurrent 5FU + MMC CI 5FU 1000mg/m2 days x4 days, bolus MMC 10mg/m2 x 1 day, given day 1 and day 29. Can consider just doing 1 cycles MMC, especially if just doing 28 treatments of RT for early stage | surgical salvage 70%, chemo improves local control and colostomy free survival | DRE and vaginal dilator as above, also with CT imaging | RTOG 9811 Ajani et al, JAMA, 2008 Gunderson, JCO, 2012 RTOG 0529 Kachnic et al, IJROBP, 2013 Olsen et al, IJROBP, 2017 NCCN. Anal Carcinoma. RT in periaortic mets Holliday et al, IJROBP, 2018 Vaginal dilator with sim Son et al, IJROBP, 2015 | |||||||||||||||||||
10 | Anal HIV+ | Test CD4. Consider treatment de-escalation if is CD4 count <200. Standard treatment can be given if CD4 >200 and this is first AIDS related complication HGSILs: treat with topical therapy, immune modulation, electrocautary ablation, infrared coagulation | Ensure following with ID and on HAART Consider decreasing dose to total 50 Gy Consider smaller field Consider holding second dose of MMC and dose reducing 5FU | Consider diversion first, especially if abscess or incontinence supine, vac loc, oral contrast, full bladder, anal bead marker | Smaller field: superior border is bottom of SI joints (as in second phase of RTOG 9811) | Consider holding second dose of MMC and dose reducing 5FU | RTOG 9811 Ajani et al, JAMA, 2008 Gunderson, JCO, 2012 RTOG 0529 Kachnic et al, IJROBP, 2013 Olsen et al, IJROBP, 2017 NCCN. Anal Carcinoma. RT in periaortic mets Holliday et al, IJROBP, 2018 Vaginal dilator with sim Son et al, IJROBP, 2015 | ||||||||||||||||||||
11 | Rectal pre-op RT International contouring guidelines 2016 | H&P. Ask about incontinence. Family history, history of IBD, genetic or hereditary disorders DRE: distance from anal verge, size, circumference, tone. Pelvic exam if female. Labs: CBC, CMP, CEA. Colonoscopy, consideration for diversion with colostomy if incontince, EUS (better than MRI), CT/MRI PET "not routinely indicated" per NCCN Surgery with LAR and TME. Goal of 12 nodes on dissection | 45 Gy to whole pelvis with boost of 5.4 Gy to tumor. First phase in 3 field prone with laterals and PA beams, then boost with opposed lateral Short course is described in the short course section Variations in sequencing exist. Consider FOLFIRINOX or FOLFOX chemo | prone, belly board, anal marker, oral contrast two hours before, full bladder | WPRT 45 Gy Boost 5.4 Gy | International concensus guidelines 2016 Always include: mesorectum (look at mesorectal fascia on CT), presacral nodes, internal iliac (aka post lateral LNs), (can omit obturators aka ant lateral LNs in T3N0 or T3N1). For the anterior border, consider extra margin for bladder variation. T3 tumors without major mesorectal invasion: the cranial border is the bifurcuation of the superior rectal artery. Since the obturator LNs are omitted, the anterior border is the coronal plane where the ureters meet the bladder, and cranially the anteterior border is posterior to external iliac nodes. The obturator nodes should be included for T3N2. Special cases: N2: as above but include the obturator nodes. Also include these nodes in T4. T4 anterior pelvic organ: include external iliac and obturator LNs. If lower 1/3 vagina involved then include inguinals. T4 anal sphincter: include obturator, external iliac, inguinal nodes, and sphincter complex. Only Include the ischial rectal fossa for direct tumor infiltration or external anal sphincter involvement. (Exclude IRF if only minor invasion into IRF and APR planned) T3 with obsturator LNs: include external iliac LNs in abdominal presacral area: Include the abdominal presacral nodes and common iliac nodes at least 5 mm above the node For boost see the seperate boost section International rectal guidelines, Valentini, 2016 RTOG colorectal atlas, 2009 econtour.org | preop with concurrent capecitabine 800mg bid M-F Consider pre-op FOLFIRINOX Or adjuvant FOLFOX LAR in 4-8 weeks then | Avoid hotspots over 10%, preferably <5% Most use no constraints PROSPECT trial constraints (not requried in the protocol, only recommended.): small bowel V35<150cc small bowel V40<70cc small bowel V45<35cc small bowel max <50 Gy Bladder mean <40 Gy Femoral heads max <50 Gy | Surgery in 4-8 weeks after chemoRT (do FOLFOX either all before chemoRT or all after surgery) | LAR/APR after RT. Vaginal dilator F/u q3-6 mos for first two years, then q6 mos with CEAs. CT imaging annually up to 5 years. Colonscopy in 1 year, then repeat in 3 years, then every 5 years | Dutch 2-yr OS 82% 5-yr LR 6% vs. 12% 10-yr LR 5% vs 11% 10-yr LR Stage III 9% vs 19% pCR 15-20% in modern series German pre-op vs. post-op sphincter preservation 39% vs. 19% acute grade 3-4 toxicity 27% vs. 40% late grade 3-4 toxicity 14% vs 24% OS 76% vs. 74% (NS) | TME unique side effects: ED, bladder dysfunction, SBO, sphincter control impairment, anastomotic stricture | International contouring guidelines, Valentini et al, Radiother and Oncol, 2016 RTOG contouring guidelines PRODIGE 23, Conroy et al, Lancet Oncol 2021 PROSPECT, Schrag et al, NEJM, 2023 CKVO Dutch trial, Kapiteijn et al, NEJM, 2001 Pre-op vs. post-op Sauer et al, NEJM, 2004 NSABP-R03, Roh et al, JCO, 2009 | ||||||||||||||
12 | Rectal - selective pre-op RT T2N1, T3N0, T3N1, >5 cm from anal verge, >3 mm radial margin, who are candidates for LAR | The PROSPECT trial was noninferior - these patients can choose whether they prefer long FOLFOX with selective RT vs. chemoRT + FOLFOX Some high T3N0s can have surgery alone T3N0 and T2N1 may also do well with chemoRT + TME alone | Treat with FOLFOX, and omit RT for good responders FOLFOX x6 → response assessment with MRI → if response <20% or <5 cycles completed → chemoRT → TME → FOLFOX x2 if response ≥20%, omit RT → TME → suggested FOLFOX x6 | FOLFOX | PROSPECT, Schrag et al, NEJM, 2023 | ||||||||||||||||||||||
13 | Rectal cancer, RAPIDO contours | For short or long course RT | RAPIDO protocol link -Include mesorectum up to 4 cm inferior to tumor -presacral and superior rectal artery nodes up to S1-S2, or if there are presacral nodes, the superior limit should be ≥1 cm above the highest node -Lateral nodes of medial rectal and obturator arteries. May exclude if the tumor is above the peritoneal reflection or above 8-10 cm from anal verge -Internal iliac nodes (as above, the superior limit is usually S1-S2) -Inguinal nodes only if involvement of anal canal distal to dentate line or distal vagina -Ischio-rectal fossa if involvement of levators or anal canal -External iliac nodes for involvement of anterior organs Boost -2 cm superior and inferior margin, within anatomical compartments -The radial margin is the anatomic mesorectum -Positive nodes are also included | Bahadoer et al, Lancet Oncol, 2020 RAPIDO protocol link | |||||||||||||||||||||||
14 | Rectal cancer, RTOG atlas or 3D fields | Less detailed than International Guidelines and RAPIDO contouring RTOG contours are essentially a recreation of 2D fields | Fields to cover obturator, int iliac and presacral nodes, entire mesorectum, which includes perirectal nodes, and tumor. Some contour, some draw blocks weigh fields 2 (PA):1:1 sup/inf: L5/S1 to bottom of obturator foramen or 3 cm below tumor, whichever is more inferior lat: 2 cm beyond pelvic brim ant: behind pubic symphysis and 3cm in front of sacral promontory post: 1 cm behind sacrum. Some say to do this for T4, and if T3 to do 2 cm border from pre-sacrum RTOG R-0012 (or simply contour what you want to target) If T4 with anterior structure invasion - move ant border in front of pubic symphisis Boost field below | RTOG contouring atlas | |||||||||||||||||||||||
15 | Rectal boost field | 5.4 Gy | Boost: Anatomical 3D contouring: Goal of local control. The radial border is the true mesorectal fascia (note the RTOG atlas definition of the "mesorectum" is not the anatomical mesorectum). Optional to include sacral hollow. Expand from GTV 1-2 cm superior and inferior. Allows for more sparing of bladder. Inclusion of nodes? Protocols and guidelines vary whether nodes should be included. If the goal is reducing risk of LR, this suggests nodes need not be included in the boost. They will be removed surgically. RTOG Guidelines Avoids making a recommendation, but does give a typical boost suggestion: 2 cm margin around GTV and include nearby sacral hollow and mesorectum per RTOG definition of mesorectum. In large tumors this can create a very large volume. PROSPECT trial 3 cm total margin from GTV and include sacral hollow but not all mesorectum. This method can result in unusually large volumes. Beam arrangement: Often laterals only since the boost is only 3 fractions. Various practices exist including laterals, 3 field, or 4 field. | RTOG guidelines PROSPECT (NCT01515787) | |||||||||||||||||||||||
16 | Rectal short course RT | Possible indications: everyone per PROSPECT and RAPIDO, or: expedited control of symptoms, surgery or chemo desired soon, limited time to complete | 5 Gy x 5 fractions to pelvis (not only to tumor) No concurrent chemo Surgery 4-8 weeks (Improved outcomes over 1 week. See Stockholm III study) | 25 Gy/ 5 fx (to pelvis) | As above: LNs are included. | none during RT Possible FOLFOX after RT | Constraints have not been outlined. This regimen should meet all SBRT constraints for 25 Gy in 5 fx. | Surgery 4-8 weeks (Stockholm III) | Long course radiation may have minor improvements in outcomes over short course in LC, late toxicity, and pCR but no consensus. Other studies show identical outcomes. (Polish, TROG, Shanghai) Stockholm III showed lower toxicity if a 4-8 week interval is used from RT to surgery. Other outcomes were the same. (1 week interval is used in most short course trials) | Timing Stockholm III, Erlandsson et al, Lancet Oncol, 2017 TROG 01.04, Ngan et al, JCO, 2012 Shanghai, Zhou et al, Surg Oncol, 2014 Polish, Bujko et al, Ann Oncol, 2016 | |||||||||||||||||
17 | Rectal post-op | NCCN allows for treatment with FOLFOX alone instead of chemoRT Indications: possibly for unexpected N1-N2 or T3-T4 tumor that was originally thought to be T1-2N0. Consider for a tumor that was excised but then found not to meet excision criteria. Also offer completion surgery instead. | Nancy Lee contouring text: 54 Gy plus boost to 55.8 Gy For positive margin, boost to 59.4-60 Gy NCCN: 45 Gy plus boost to 50.4-54 Gy total For positive give 10-20 Gy boost with EBRT or brachy | WPRT 45-54 Gy Boost to 50.4-60 Gy | Consider following the logic of the pre-op international concensus guidelines. Classically, the inferior border changes If LAR, 1 cm below anastamosis or rectal stump If APR, extend inferior border down to scar | Concurrent capecitabine FOLFOX alone is another option if RT not being done | Nancy Lee et al, Target Volume Delineation for Conformal and Intensity-Modulated Radiation Therapy, 2015 NSABP-R03, Roh et al, JCO, 2009 NCCN. Rectal Cancer. | ||||||||||||||||||||
18 | Rectal cancer, inguinal node recurrence | FNA Consider excisional biopy of node, but healing results can be morbid especially in overweight patients | RT to inguinal nodes on that side with concurrent capecitabine | Hagemans et al, Ann Surg Oncol, 2019 | |||||||||||||||||||||||
19 | Rectal organ sparing | 45 Gy WPRT then: Boost up to 54-60 Gy contact x-ray brachytherapy boost 90 Gy/3 fx, especially for size ≤3 cm offer local excision only for size <2 cm (GRECCAR 2) | WPRT 45 Gy EBRT boost to 50.4-60 Gy Contact brachy boost + 90 Gy/ 3 fx | capecitabine | NCCN: endoscopy every 3-4 months for first 2 years or MRI every 6 months for 3 years | cCR in 87% in IWWD cCR in 50% with 50.4 Gy and bx on f/u. Of these, nearly all (95%) are salvaged (Sao Paulo) CR in 80% with 60 Gy chemoRT. Of CR patients, 1-yr LR 16% (Danish) | OPRA, Garcia-Aguilar et al, JCO, 2022 OPERA, Gerard et al, Lancet Gastroenterol Hepatol, 2023 Danish, Appelt et al, Lancet, 2016 Sao Paulo, Habr Gama et al, Lancet, 2014 IWWD, van der Valk et al, Lancet, 2018 GRECCAR 2, Rullier et al, Lancet, 2017 | ||||||||||||||||||||
20 | T1 rectal meeting criteria for WLE | Transanal excision or TEM, transanal endoscopic microsurgery Get MRI/EUS to confirm resectability Indications: <3 cm, <30% circumference, margin >3mm, mobile, within 8 cm of anal verge, T1, endoscopically removed polyp, well/mod differentiated, no LVSI or PNI | NCCN Post-op treatment indications: If additional high risk features (poorly diff, +M, LVSI, or invasion into lower third of submucosa "sm3", T2): do LAR/APR, then post-op chemoRT if pT3-T4 or N1-N2 If pT3-4N0 or any N1-N2, then treat with chemoRT | <30% circumference, <3cm in size, clear margins, T1, mobile, within 8 cm of anal verge, no LVSI, grade 1/2, no LN) | NCCN. Rectal Cancer. | ||||||||||||||||||||||
21 | Esophagus T1a, T1b, Tis, and T2 | Tis: ER followed by ablation T1a: ER and ablation T1b: esophagectomy alone T2: can be treated with esophagectomy alone if noncervical, low risk lesion < 2cm, grade 1-2 | NCCN. Rectal Cancer. | ||||||||||||||||||||||||
22 | T2 adjuvant radiation | Indications: -R1/2: chemoRT -adeno, R0 and N0: surveillance or consider CRT if lower esophagus/GEJ, grade 2-3, +PNI/LVI, age <50 -R0 and N+ (any T): CRT or chemo alone; if R1/2 = CRT (observation for all R0 SCC) | See gastric | MacDonald et al, NEJM, 2001 Smalley et al, JCO, 2012 Esophageal and Esophagogastric Junction Cancers. NCCN 2021. | |||||||||||||||||||||||
23 | Cervical esophagus | H&P. Smoking cessation Labs: CBC, CMP, liver panel Imaging: EGD with biopsy, EUS, CT, PET functional testing: consider bronch to look for fistula and PFTs in preparation for therapy if upper lesion. If fistula present place stent | 50.4 Gy, or dose escalate to 60-70 Gy since unresectable. Include SCV nodes in initial volume to 45 Gy plus margin on esophagus | supine, wingboard, small amount of oral contrast | 50.4-70 Gy | Can use IMRT, or 3D techniques. Include esophagus as below plus SCV nodes. lateral parallel opposed (or oblique) portals to the primary and a single anterior field for the SCV and mediastinal nodes alternatively 4 field box with wax bolus around the neck above the shoulders Or anterior wedged pairs, or posterior obliques with a single AP field | Taxol 50 and carbo AUC 2 both given weekly Or cisplatin and 5FU (Zenda) | MS 15 mos LC 50% 2-yr OS 35% (Minsky) CR 73% (Zenda) | RTOG 9405, Minsky et al, JCO, 2002 Zenda et al, IJROBP, 2016 CROSS Hagan et al, NEJM, 2012 Shapiro et al, Lancet Oncol, 2015 | ||||||||||||||||||
24 | Esophagus locally advanced, ≥T2 | H&P. Smoking cessation Labs: CBC, CMP, liver panel Imaging: EGD with biopsy, EUS, CT, PET functional testing: consider J tube, sometimes PEG tube | 45 Gy in 25 fx followed by boost of 5.4 Gy in 3 fx. Include celiac for distal and GEJ tumors 41.4 Gy alone is an option for those who are likely to undergo surgery. | supine, wingboard, small amount of oral contrast | Pre-op or definitive PTV1: 45 Gy PTV boost: 5.4 Gy Pre-op only 41.4 Gy | CTV = primary with 4 cm sup/inf and 0.5-1 cm radial. Include SCV nodes for tumor above carina. Include celiac nodes for distal and GEJ. If the celiac and volumes do not connect, contour PA region down aorta to connect esophagus portion with celiac. Lung is tradiationally not cropped from the CTV, but convincing reasons why not are lacking. PTV of 0.5 cm For Boost PTV add 0.5 cm to GTV Wu, esophagus atlas, IJROBP, 2016 | Taxol 50 and carbo AUC 2 both given weekly Adjuvant nivolumanb for partial response to chemoRT | RTOG 1010 Lung V5<50 V10<40 V20<25 V30<20 MLD <20 Heart V40<50, Mean <30, max <52 Kidney V20<30, Max<45 Cord <45 Gy Liver Mean <21 Gy, V30<30 | risk of positive nodes: T1a: 7% T1b: 20% T2: 40% Anatomic divisions Sternal notch -> Upper thoracic -> azygous vein -> middle thoracic -> inferior pulmonary vein -> lower thoracic | 5-yr OS 47% MS 49 mos pCR SCC 46% pCR adeno 23% LRR 3.3% DR alone 20% | CROSS Hagan et al, NEJM, 2012 Shapiro et al, Lancet Oncol, 2015 Checkmate 577, Kelly et al, NEJM, 2021 RTOG 1010 (NCT01196390) Wu et el, IJROBP, 2015 | ||||||||||||||||
25 | Esophagus unresectable, non-cervical | 45 Gy with boost to 50.4 as above No evidence for dose escalation below cervical location | PTV1: 45 Gy PTV boost: 5.4 Gy | Taxol and carbo, or cisplatin and 5FU. | CROSS Hagan et al, NEJM, 2012 Shapiro et al, Lancet Oncol, 2015 | ||||||||||||||||||||||
26 | Gastric post-op NCCN indications: R1/R2 resection Consider also for those who did not undergo D2 resection with high-risk features such as poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion, or <50 years of age | History and physical Labs: CBC, CMP, liver panel Upper GI with biopsy and H pylori testing, EUS, CT A/P, consider PET Functional testing: J tube consult if Kcal <1500, renal perfusion scan (not needed if planning for IMRT) Surgery: subtotal gastrectomy, 5 cm margin on tumor (otherwise total gastrectomy) with D2 dissection removing >15 LNs, ex lap to look for peritoneal disease Total gastrectomy for large or proximal/fundus lesions Ivor-Lews esophagectomy if tumor at GEJ, Seweirt III | 45 Gy/ 25 fx Contouring: Include anastomosis. Always include whole stomach except for GEJ tumors. Include nodes related to adhesion for T4. For T3N0, may cover only perigastric nodes. For N+ or T4, cover extra nodes: Sources vary on nodes to cover. Simple method: Include all nodes for each site, except spleen nodes only for proximal and middle location Gunderson: Elective nodes (always include perigastric, celiac, SMA?, PH?, and around aorta): GEJ: proximal perigastric, periesophageal, PA/celiac, MS Cardia/prox 1/3: perigastric, celiac/PA, splenic, suprapancreatic Body/middle 1/3: perigastric, celiac, splenic, suprapancreatic, pancreatoduodenal, portahepatis antrum/pylorus/distal 1/3: perigastric, celiac, suprapancreatic, pancreatoduodenal, porta hepatic, optional splenic hilum | Historically renal scan was done first because 3D fields may damage kidneys. If doing IMRT a renal scan should not be necessary supine, 4DCT, wingboard, empty stomach, small amount of oral contrast. Treat daily on empty stomach | 45 Gy | IMRT is allowed on NCCN. Use daily CBCT. 3D Anteroposterior–Posteroanterior (AP–PA) Field Superior border: (remember, celiac at T12 (or top of L1 and SMA at L1. IMA at L3) bottom of T8 or T9 to cover the celiac axis, GE junction, fundus, and the dome of the left hemidiaphragm. Inferior border: bottom of L3 to cover the gastroduodenal nodes and the antrum. Left border: Include two thirds to three fourths of the left hemidiaphragm to cover fundus, suprapancreatic nodes, and splenic nodes. Right border: Field is 3 to 4 cm lateral to the vertebral bodies to cover the antrum, porta hepatis, and gastroduodenal nodes. Lateral Field (opposed lats if doing 4 field. AP/PA only is possible in many patients. Weight AP>PA to get off cord) Anterior border: Anterior abdominal wall. Posterior border: one half to two thirds of the vertebral bodies. Post-op gastric contouring atlas, Harvard, Wo, IJROBP, 2012 Nancy Lee et al, Target Volume Delineation for Conformal and Intensity-Modulated Radiation Therapy, 2015 | Concurrent 5FU or capecitabine with 1 cycle before chemo and 2 cycles after The non-concurrent portion can be done with ECF, epirubicin, cisplatin, 5FU, or with 5FU/LV. ECF gives same outcomes as 5FU/LV and les toxocity | cord dmax<45 heart V40<30% 2/3 of one kidney<20 Gy liver V30<60% bowel max<54 Gy, V45<15% (20cc), V30<200cc | Start 20-40 days after surgery. One cycle of chemo is given during wait | If no proximal stomach, make sure to supplement with B12, Ca, and iron | 5-yr OS 44% (MacDonald) MS 36 mos LR 7% | INT 0116, Macdonald et al, NEJM, 2001 CRITICS, Cats et al, Lancet Oncol, 2018 Nancy Lee et al, Target Volume Delineation for Conformal and Intensity-Modulated Radiation Therapy, 2015 NCCN 2023. | |||||||||||||||
27 | Gastric T1-T2 | Tis: ER T1a: ER T1b: surgery | NCCN. Gastric Cancer. | ||||||||||||||||||||||||
28 | Gastric pre-op RT | Under protocol in TOPGEAR Investigational | 45 Gy in 25 fx | 45 Gy | Carbo taxol (category 1 NCCN) Or cis/5FU or oxali/5FU | pCR 26%, 1 yr OS 72%, Median OS 23 mos If pCR, then 1 yr OS 82% | RTOG 9904, Ajani et al, JCO, 2006 Wu et al, World J Gastrointest Surg, 2012 TOPGEAR, Leong et al, BMC Cancer, 2015 | ||||||||||||||||||||
29 | Gastric peri-op chemo | T2 and above | No RT | perioperative FLOT (docetaxel, oxaliplatin, 5-FU, LV) (better OS than ECF) | Periop chemo vs. post-op chemo RT results in same LC and OS, but post-op chemoRT has less heme toxicity in CRITICS study. But, peri-op FLOT has better OS than peri-op ECF in FLOT4-AIO study | FLOT4-AIO, Al-Batran et al, ASCO, 2017 | |||||||||||||||||||||
30 | Borderline pancreas | Borderline resectable: Head/uncinate process: contacts common hepatic artery or SMA <180, but NOT celiac Body/tail: celiac axis contact <180. Can contact >180 if no involvement of aorta or gastroduodenal artery (some say this is unresectable) SMV or PV of >180 is borderline resectable if suitable vessel is present proximal and distal for reconstruction. If contour irregularity or thrombus in SMV/PV, then tumor can involve only <180 and be borderline. Tumor can contact IVC and be borderline. | 50.4 Gy, up to 60 Gy, possibly more PREOPANC: gem x3 cycles 1000 mg/m2 + 36 Gy/ 15 fx IMRT in 2.4 Gy per fx during cycle 2 → surgery → adjuvant gem x4 Or SBRT as below | supine, wingboard, gating/4DCT, abdominal compression, oral contrast, IV contrast in late arterial/early portal phase (Scan delay of 35-50 seconds) | 50.4-60 Gy 36 Gy/ 15 fx (w gem) | GTV is gross disease plus nodes. CTV varies per study. Some use no CTV. Might extend CTV toward the borderline vessels. Do not extend CTV into duodenum. ESTRO-ACROP says to consider a CTV if tumor size <3cm PTV per institution. Use 4DCT or gating | Induction FOLFIRINOX or gemzar + nab-paclitaxol Concurrent capacitabine 825 mg BID concurrent with conventional high dose gem concurrent with 15 fractions | Conventional: stomach, duodenum, small intestine Max dose <54 Gy. Some protocols allow max dose <58 Gy Liver mean <25Gy Cord max 45 Gy single kidney: D30%<18Gy 15 fractions See Koay et al, PRO, 2020 for 15 fractions constraints, although not necessarily for chemo (The dose contraints in PREOPANC were liberal: no limitation on small bowel was required) | borderline resectable = no DM, abutment of SMA up to 180 degrees, SMV/portal vein impingement or narrowing, SMF occlusion that can be reconstructed, gastroduodenal artery encasement up to hepatic artery. | RTOG 0848, Safran et al, JCO, 2017 NCCN. Pancreatic Adenocarcinoma. LAP07, Hammel et al, JAMA, 2013 PRODIGE 24/CCTG PA.6, Conroy et al, NEJM, 2018 PREOPANC, Versteijne et al, JCO, 2022 Dose escalation Crane et al, J Radiat Res, 2016 | |||||||||||||||||
31 | SBRT pancreas, borderline or unresectable | SBRT 25-50 Gy in 3-5 fractions. Consider 45-50 Gy to tumor and 25-35 Gy to the posterior and vessels margin. May need to undercover the tumor slightly to spare bowel. | empty stomach, supine, wingboard, gating/4DCT, abdominal compression, IV contrast in late arterial/early portal phase (Scan delay of 35-50 seconds). Fiducials if required. Oral contrast could enlarge bowel size Fuse with MRI | SBRT 25-50 Gy/ 5 fx consider SIB to vessels | GTV: primary tumor, no nodes CTV: optional. Consider extending CTV posteriorly to vessel margin. ESTRO-ACROP says to consider a CTV if tumor size <3cm PTV: per institution, 5 mm | Induction first with FOLFIRONOX or gem abraxane PREOPANC used concurrent, induction, and adjuvant gemcitabine | TROG and AGITG guidelines (5 fractions) Duodenum/small bowel/stomach Dmax 0.5 cc <33 Gy (VA <35) V30 <5 cc (VA <10 cc) Duodenum/small bowel/stomach PRV Dmax 0.5 cc <38 Gy (VA <40) PTV40 D99 >30 (VA > 25) PTV40 EVAL D90 >100 (VA > 90) CTV D99 > 33 (VA > 30) PTV40 D0.05 max 110-130 (VA >140 or <110) Koay et al, PRO, 2020 (Rx 50 Gy/5 fx with SIB 33 Gy) iduodenum V40 <0.5cc, V35 < 1cc, V30 <3cc istomach, sm bowel V 40 <0.5cc, V35 <1cc, V30 <2cc liver V12 <50% bile duct max <55 Gy PTV high (50 Gy) covered to 90-95% PTV low (33 Gy) covered to 98% posterior tumor vessels covered to 40 Gy | Petrelli et al, IJROBP, 2017 PRODIGE 24/CCTG PA.6, Conroy et al, NEJM, 2018 Dose escalation Crane et al, J Radiat Res, 2016 Dose constraints TROG and AGITG, Oar et al, PRO, 2019 Koay et al, PRO, 2020 | |||||||||||||||||||
32 | Post-op pancreas, head or tail | H&P Labs: CBC, CMP, CEA, CA-19-9, amylase, lipase, liver panel EUS (preferred) with biopsy, CT C/A/P with contrast in 3 phases per pancreatic protocol. Only do ERCP/MRCP if no mass seen. Can consider PET, but not a substitute for high quality CT --> Whipple procedure (for head and body tumors) Distal pancreatectomy for tail tumors (not Whipple) Three phase pancreas CT: -Noncontrast phase: Will show calcifications that could otherwise be confused with contrast -Early arterial phase, 20 sec. Will show arterial anatomy -late arterial/early portal phase. Scan delay of 35-50 seconds. Optimal attenuation between enhancing parenchyma and tumor in this phase. -Late portal, venous phase: scan delay of 70-80 seconds. Shows lymph nodes, liver mets, peritoneal implants | 50.4 to entire tumor bed and nodes or 45 Gy to tumor bed and nodes + 5.4 Gy boost with 2 cm margin to tumor bed Decreasing in use as more efficacious chemo regimens are discovered and trials show lack of OS benefit with RT. Some may treat only post-op bed for postive margin. | supine, wingboard, gating, abdominal compression, oral contrast, IV contrast. | nodes: 45 Gy boost -M to 50.4 Gy boost +M to 60-66 Gy or single phase 50.4 Gy | Tumor bed: per operartive and path reports, fusion of pre-op imaging, pancreatic-jejunostomy anastamosis Per protocol field to cover post-op bed and nodes: expand clips, SMA, celiac, PJ, PV all with 1cm margin, then aorta (with 3cm right, 2cm ant, 1 cm left and 0.2 cm post), cover aorta from top of field made by other structures down to bottom of L2 (lower if preop GTV lower). However, take note of individual anatomy. Mnemonic: "PPACTS" Head nodes: common hepatic, celiac, hepatoduodenal, superior mesenteric, anterior and posterior pancreato-duodenal, PA nodes from celiac to left renal vein, superior and inferior pancreatic head nodes (ESTRO-ACROP) Body and tail nodes: common hepatic, celiac, hepatoduodenal, superior mesenteric, PA nodes from celiac to left renal vein, sub pancreatic nodes, splenic artery (ESTRO-ACROP) RTOG post-op pancreas atlas ESTRO-ACROP pancreas target guidelines Reduced volumes: Dholakia, IJROBP, 2013 econtour.org | Consider induction FOLFIRINOX or gemzar + nab-paclitaxol Then concurrent capacitabine 825 mg BID If induction chemo is not used, give adjuvant mFOLFIRINOX | 9704 field borders - T11 to L3, 2 cm margin on tumor, 2 cm from R vertebral body (includes hepatic hilum, pancreatic remnant, and 1.5-2.0 cm from vertebral bodies to cover periaortics). Laterals: posterior border split vertebral body, ant border 2 cm in front of mass and block out small bowel if able. | Median OS 54 mos, DFS 22 mos with FOLFIRINOX (PRODIGE) 3-yr OS 30%, LF 30%, MS 21 mos, DM 73% (RTOG 9704) | PRODIGE 24/CCTG PA.6, Conroy et al, NEJM, 2018 ESTRO-ACROP guidelines, Brunner et al, Radiother Oncol, 2020 RTOG 9704 Regine et al, JAMA, 2008 Regine et al, Ann Surg Oncol, 2011 Reduced volumes Dholakia et al, IJROBP, 2013 | |||||||||||||||||
33 | Unresectable pancreas | Induction gem-nab-paclitaxel or FOLFIRINOX Often treated with chemo only, not radiation 50.4-70 Gy, consider BED near 100 if feasible. Some regions may be undercovered by dose. | supine, wingboard, gating, abdominal compression, oral contrast, IV contrast in late arterial/early portal phase (Scan delay of 35-50 seconds) | 50.4-70 Gy | GTV is gross disease. Typically no elective nodal volume. Many use no CTV. Consider 0.5-1 cm. ESTRO-ACROP says to consider a CTV if tumor size <3cm PTV per institution. | Consider induction FOLFIRINOX or gemzar + nab-paclitaxol Then concurrent capacitabine 825 mg BID | stomach, duodenum, small intestine Max dose <54 Gy. Some protocols allow max dose <58 Gy Liver mean <25Gy Cord max 45 Gy single kidney: D30%<18Gy | MS 16 mos, LC 45% (LAP 07) OS benefit with RT in GITSG and ECOG studies. LC benefit in LAP07. | RTOG 0848, Safran et al, JCO, 2017 Conroy et al, PRODIGE 24/CCTG PA.6, NEJM, 2018 NCCN LAP07, Hammel et al, JAMA, 2013 Dose escalation Crane et al, J Radiat Res, 2016 | ||||||||||||||||||
34 | SBRT liver mets | Consider dosing per RTOG 1112 below in HCC section | Simulate in supine position with SBRT body fixer, abdominal compression, IV contrast in portal venous phase, 4DCT or breath hold at exahalation. Contour on MinIP. Fiducials needed for CyberKnife | SBRT 27.5-50 Gy/ 5 fx | CTV 3-5 mm optional PTV per institution: goal < 10 mm | NRG GI003 The rx dose is guided by the mean liver dose achievable: 50 Gy for ≤13 Gy of mean liver minus GTV 45 Gy for ≤14 Gy 40 Gy for ≤15 Gy 35 Gy for ≤15.5 Gy 30 Gy for ≤16 Gy Deviations of 1% (or 2% variation acceptable) from mean liver dose for each dose level were allowed small bowel, duodenum, stomach, esophagus D0.5cc <30 Gy Large bowel D0.5cc<32 Gy Both kidneys D33% < 15 Gy Both kidneys mean < 10 Gy Both kidneys D10% < 7 Gy Heart D0.5cc < 20 Gy Gallbladder D0.5cc < 55 Gy (RTOG 1112) | premedicate with anti-emetics, PPI | Median OS 22 mos LC for BED >100 of 77% LC for BED <100 of 60% LC for tumors >40 cc of 52 mos LC for tumors <40 cc of 39 mos | Lee et al JCO, 2009 Rusthoven et al, JCO, 2009 Mahadevan et al, Radiat Oncol, 2018 RTOG 0438 (NCT00255814) RTOG 1112 (NCT01730937) | ||||||||||||||||||
35 | HCC with tumor thrombosis, pre-op | History: alcohol abuse, bleeding, esophageal varices, encephalopathy, lactulose, lasix, ascites Imaging: triple phase MRI liver (CT can also be done) (MRI results should be diagnostic. Bx not needed. Enhances on arterial phase and washout on venous phase), CT abdomen Labs: AFP, liver labs, hepatitis panel, INR, plt, albumin Calculate Child Pugh Score (if C, mortality risk may outweight benefits). Scoring factors include bilirubin, albumin, INR, ascites, encephalophaty | 18 Gy/ 3 fx then surgery 3 months after RT | Simulate in supine position, abdominal compression, IV contrast in portal venous phase, 4DCT or breath hold at exahalation. Contour on MinIP. | 18 Gy/ 3 fx | 3DCRT CTV 5-10 mm PTV 5-10 mm per institution | 3 mos after RT | 1-yr OS 75% vs. 43% 2-yr OS 27% vs. 9% PR 21%, CR 0% | Wei et al, JCO, 2019 | ||||||||||||||||||
36 | HCC SBRT | In RTOG 1112: total volume up to 20 cm, ≤5 mets, any single lesion up to 15 cm, and macrovascular invasion were permitted History: alcohol abuse, bleeding, esophageal varices, encephalopathy, lactulose, lasix, ascites Imaging: triple phase MRI liver (CT can also be done) (MRI results should be diagnostic. Bx not needed. Enhances on arterial phase and washout on venous phase), CT abdomen Labs: AFP, liver labs, hepatitis panel, INR, plt, albumin Calculate Child Pugh Score. Scoring factors include bilirubin, albumin, INR, ascites, encephalophaty | SBRT dose as high as feasible per mean liver dose achievable (NRG GI-003) 50 Gy for ≤13 Gy of mean liver minus GTV 45 Gy for ≤14 Gy 40 Gy for ≤15 Gy 35 Gy for ≤15.5 Gy 30 Gy for ≤16 Gy Various doses have been used in Phase I/II trials. Consider combining with TACE RT can be used for bridge to transplant if patient meets UNOS criteria Potentially curative for patients who aren't operable candidates, but not much data. Surgical resection is preferred | Simulate in supine position with SBRT body fixer, abdominal compression, IV contrast in portal venous phase, 4DCT or breath hold at exahalation. Contour on MinIP. Fiducials needed for CyberKnife | SBRT 30-50 Gy/ 5 fx | PTV per institution: goal < 10 mm CTV: none (consider including previous TACE or RFA sites, or tumor thrombi) | NRG GI003 The rx dose is guided by the mean liver dose achievable: 50 Gy for ≤13 Gy of mean liver minus GTV 45 Gy for ≤14 Gy 40 Gy for ≤15 Gy 35 Gy for ≤15.5 Gy 30 Gy for ≤16 Gy Deviations of 1% (or 2% variation acceptable) from mean liver dose for each dose level were allowed small bowel, duodenum, stomach, esophagus D0.5cc <30 Gy Large bowel D0.5cc<32 Gy Both kidneys D33% < 15 Gy Both kidneys mean < 10 Gy Both kidneys D10% < 7 Gy Heart D0.5cc < 20 Gy Gallbladder D0.5cc < 55 Gy (RTOG 1112) | NCCN. Hepatobilliary Cancers, 2019. RTOG 1112, Dawson et al, ASTRO, 2022 NRG GI003 (NCT03186898) TACE+RT Yoon et al, JAMA Oncol, 2018 Meng et al, Radiother Oncol, 2009 RT after failure of TACE Comito et al, EASL, 2020 Surgery vs. RT Su et al, IJROBP, 2017 | |||||||||||||||||||
37 | Biliary (intra/ extrahepatic cholangio-carcinoma, gallbladder) | CT/MRI, chest CT, cholangiography, consider CEA and CA 19-9, amylase, lipase, LFTs, EUS Distal extrahepatic: whipple | positive margin in extraheptatic or gallbladder: 4 cycles capecitabine/gem then RT + capecitabine to 45 Gy then 54-59.4 Gy boost (SWOG 0809) For negative margins treat with 6 mos capecitabine alone Less evidence for RT for R1 in intrahepatic | PTV1: 45 Gy PTV boost to 54-59.4 Gy | CTV1 = tumor bed, portal vein nodes, sometimes pancreatic or celiac depending on location CTV2 = tumor bed (often use wide margins such as +1.5 cm or more) and positive margins, ITV on 4D CT and 0.5 cm PTV radially and 0.7 cm sup/inf Consider expanding CTV bigger along ducts into liver | R1: Concurrent cape with RT Negative margins: 6 mos capecitabine Unresectable for extra or intrahepatic: gem/cis without RT | SWOG 0809 extrahepatic biliary: MS 35 mos, 2-yr OS 65% cis/gem systemic therapy only: MS 12 mos (ABC trial) | SWOG 0809, Ben-Josef et al, JCO, 2015 ABC-02, Valle et al, NEJM, 2018 ASCO Biliary guidelines for adjuvant therapy, Shroff et al, JCO, 2019 | |||||||||||||||||||
38 | Anal adenocarcinoma | Treat as rectal cancer, no matter what location of anus | cover inguinals with RT | NCCN. Anal Carcinoma, 2019. | |||||||||||||||||||||||
39 | Anal cancer with oligometastatic disease to liver, lung, PA nodes | ChemoRT to primary and oligometastases | PA nodes 3-yr DFS 42%, 3-yr DM 50%, 3-yr OS 67% | NCCN. Anal Carcinoma, 2019. Holliday et al, IJROBP, 2018 | |||||||||||||||||||||||
40 | Oligometastatic rectal with resectable liver or lung mets | Synchronus=observed prior to definitive treatment or 3 months after (Metachronus= developed after initial treatment) | Consider: neoadj chemoRT (with or without initial FOLFOX) --> surgery of primary AND resection of mets (or SBRT of mets)--> FOLFOX x6 SBRT can be used but colorectal tumors are relatively radioresistant and surgery is preferred | NCCN. Rectal Cancer. | |||||||||||||||||||||||
41 | Colon surveillance | Lynch syndrome: colonoscopy at age 20-25 or earlier at 2-5 years prior of relative diagnosed prior to age 25, then repeat every 1-2 years FAP: Most are APC+. This is autosomal dominant version. if APC+, start screening age 15 and do yearly. The APC negative type is autosomal recessive and can be screened per normal guidelines Cowden and Li-Fraumini: counsel per breast and ovarian guidelines. No increase in colon screening | Lynch syndrome=hereditary nonpolyposis colorectal cancer. Endometrial, ovarian, and colon, other parts of GI tract cancers. MSH and MLH. Autosomal dominant Li-Fraumini: sarcoma, adrenal, breast, brain, leukemia (SBLA). P53, autosomal dominant. Cowden: hemartomas, breast, thyroid, uterus, thyroid, kidney, colorectal cancers. PTEN Mutation. Autosomal dominant | NCCN. Genetic/Familial High-Risk Assessment, 2019. NCCN. Colorectal Cancer Screening, 2019. | |||||||||||||||||||||||
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