Anal cancer radical
Radical chemoradiotherapy (any tumour above T1 margin tumour)
T1-T2 N0 = 50.4Gy/28#/5.5 weeks with concurrent IV mitomycin C 12mg/m2 (max 20mg) with oral capecitabine 825mg/m2 on days of RT.
T3-T4 or N+ = 53.2Gy/28#/5.5 weeks with concurrent IV mitomycin C 12mg/m2 (max 20mg) with oral capecitabine 825mg/m2 on days of RT. 53.2Gy to gross anal disease and CTVN3 (nodes >3cm), 50.4Gy to gross nodal disease.
Elective nodes (T2 plus) treated to 40Gy/28#/5.5 weeks.
CTVA includes entire anal canal.
Elective nodal areas should include: bilateral inguinal femoral, external iliac, internal iliac, obturator, pre sacral nodes and lower 5cm of mesorectum. If GTV extends into mesorectum the entire mesorectum should be in elective volume. This includes tumours which extend into the anorectal junction.
CI or PA nodes = M1
Anal cancer adjuvant
& indication
Consider if positive margin or close (<1mm) or unexpected finding.
Adjuvant chemoradiotherapy to anal margin and canal 41.4Gy/23#/4.5 weeks with concurrent IV mitomycin C 12mg/m2 (max 20mg) with oral capecitabine 825mg/m2 on days of RT.
Plus nodes if > 2cm (>/=T2)
Elective nodal areas should include: bilateral inguinal femoral, external iliac, internal iliac, obturator, pre sacral nodes and lower 5cm of mesorectum. If GTV extends into mesorectum the entire mesorectum should be in elective volume. This includes tumours which extend into the anorectal junction.
Rectal cancer low risk
Upto T3aN0 No EMVI, CRM not threatened
= surgery alone
Rectal cancer intermediate risk
> /= T3b, CRM not threatened, N and EMVI + or -
Short course radiotherapy 25Gy/5#/1 week followed by either immediate or delayed (6-8 weeks) surgery.
Rectal cancer high risk
CRM + or threatened (<1mm), tumour encroaching on intersphincteric plane or levator involvement.
Short course radiotherapy 25Gy/5#/1 week followed delayed (6-8 weeks) surgery.
Long course chemo-radiotherapy 50Gy/25#/5weeks with concurrent capecitabine 900mg/m2 BD PO on RT days.
Young, fit, high risk e.g. T4, N2 (pMMR only)
Total neoadjuvant therapy
Rapido protocol of Short course radiotherapy 25Gy/5#/1 week plus 3m CAPOX (D1 oxali 130mg/m2 IV, Capecitabine 1000 mg/m2 D1-D14, 21 day cycle x 4), followed by surgery.
Prodige protocol - 3m FOLFIRINOX chemotherapy (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2, and fluorouracil 2400 mg/m2 intravenously every 14 days for 6 cycles), long course chemo-radiotherapy 50Gy/25#/5weeks with concurrent capecitabine 900mg/m2 BD PO on RT days, followed by surgery (total mesorectal excision).
Elective nodes: Int iliac, obturator, presacral and mesorectal
Spiel: I would outline the internal iliac and pre-sacral nodes from S1/2 junction. Int iliac, with 7mm margin around vessels down to obturator internus, presacral with 10mm roller ball down to the caudal border of mesorectum.
I would outline the mesorectum from S2/3 junction down to where mesoractal fat disappears (insertion of levator ani muscle into the external sphincter muscles). Obturator nodes, with a 17mm rollerball from the top of obturator internus to where obturator artery leaves the pelvis.
General - go 2cm above highest involved node - so may extend CTVe accordingly.
External iliac, CI considered metastatic.
Inguinal considered metastatic unless tumour is below the dentate line.
Presacral: 10mm rollerball (or 7mm ant to sup rectal art/IMA whichever is more anterior) from the S1/2 junction to caudal border of mesorectum.
Mesorectum: From S2/3 junction down to where mesoractal fat disappears (insertion of levator ani muscle into the external sphincter muscles).
Int iliac - From ant border of S1/2 to obturator internus muscle (top of obturator nodes). Outline vessels, plus 7mm margin.
Obturator - 17mm roller ball, Superiorly, from first slice showing obturator internus down to where obturator leaves the pelvis. Include areas of bladder if present.
Rectal adjuvant radiotherapy
If CRM + (or threatened <1mm) + no pre-op RT.
Adjuvant radiotherapy 45Gy/25#/5 weeks with a simultaneous integrated boost to 50Gy/25#/5 weeks to residual macroscopic disease or R1 resection.
High risk BCC radical radiotherapy?
High risk = micronodular, infiltrative, PN spread, recurrent, morphoeic, positive/close margins.
Radical radiotherapy 55Gy/20#/4 weeks.
Margins:
CTV 0.5cm - low-risk (nodular or superficial) and well defined.
CTV 1cm - poorly defined or high risk (micronodular, infiltrative)
PTV +0.5cm for electrons.
Alternative:
Frail and field size <3cm 18-20Gy/1#
Field size < 3.5cm - 35Gy/5#/1week, 45Gy/10#/2weeks (RCR any size)
Field size <5cm diameter 50Gy/15# (RCR any size)
Poor tolerance/big 60Gy/30#
BCC adjuvant radiotherapy
Indications: positive margins, recurrence
Relative indications (not in QART): Challenging sites, T3/4 disease, close margin at high risk site e.g. ear canal.
Adjuvant radiotherapy 55Gy/20#/4 weeks.
Margins:
CTV 0.5cm - low-risk (nodular or superficial) and well defined.
CTV 1cm - poorly defined or high risk (micronodular, infiltrative)
PTV +0.5cm for electrons.
Alternative:
Frail and field size <3cm 18-20Gy/1#
Field size < 3.5cm - 35Gy/5#/1week (RCR lesions <4cm), 45Gy/10#/2weeks (RCR any size)
Field size <5cm diameter 50Gy/15# (RCR any size)
Poor tolerance/big 60Gy/30#
SCC adjuvant or radical radiotherapy
+ indications
QART Adjuvant treatment for:
o Incomplete excision
o Locally Recurrent disease
o Margin < 1mm and one other risk factor or immunocompromised
o Perineural invasion
o In a completely excised T3 tumour, consider RT if more than one of: size > 40mm, depth > 6mm, PNI of defined nerve or N ≥ 0.1mm or immunosuppression
I would offer radical/adjuvant radiotherapy 55Gy/20#/4weeks.
50Gy/15# - shorter fractionations may be used for frail patients with smaller field sizes (RCR say any size).
Poor tolerance/big 60Gy/30#
CTV 1cm
PTV +0.5cm for electrons.
T3: any of the following:
tumour >4 cm
minor bone erosion
perineural invasion, defined as either of the following:
clinical or radiographic involvement of named nerves without skull base invasion or transgression, or
tumour infiltration of the sheath of a nerve deeper than the dermis or measuring ≥0.1 mm in calibre
deep invasion, defined as either of the following:
invasion beyond the subcutaneous fat, or
invasion >6 mm from granular layer of adjacent epidermis to base of tumour
Adjuvant radiotherapy dose/# to nodal regions considered at high risk of relapse after lymphadenectomy?
Skin SCC
60Gy/30#/6 weeks (QART recommended dose)
For large fields/elective regions consider 50Gy/25#/5weeks (RCR also recommends).
Adjuvant RT to areas with high pathological risk features in the head and neck region dose/#?
Skin Scc
E.g. ECS
66Gy/33#/6.5weeks
Merkel cell primary RT dose/#?
If surgery not possible and M0 can consider primary RT.
60-66 Gy in 30-33 fractions in 6-6.5 weeks
55Gy in 20 in 4 weeks
Single or 2 dose levels used
Adjuvant RT following merkel cell excision dose/#?
· Consider prophylactic radiotherapy to draining lymph node region in all patients who have had Merkel cell carcinoma excised and if no SLNB performed.
· Adjuvant after nodal dissection for stage III disease and extracapsular spread or multiple nodes
60-66 Gy in 30-33 fractions in 6-6.5 weeks
55Gy in 20 in 4 weeks
Single or 2 dose levels used
Melanoma indications and dose/# for RT?
Definitive RT if unresectable 60Gy/30#/6 weeks (QART)
RCR says 50Gy/15#/3weeks.
Mucosal melanoma (nasal cavity) - always for adjuvant RT post surgery.
Adjuvant
- involved or close margins and re-excision not possible.
-post -lymphadenectomy - ECS and/or multiple nodes.
Dose/# for all = 60Gy/30#/6weeks.
QART Can lower dose to 50Gy/30# where PTV extends into pelvis.
QART can escalate to 66Gy/33# for nasal cavity mucosal melanoma.
Palliative skin lesion?
8Gy/1# painful skin lesion poor PS (2 in exam example)
20Gy/5#
Lots of other options (RCR): 20Gy/2#/1 week apart
Melanoma:
Limited evidence suggests 30Gy/10#/2weeks gives better palliation (RCR document).
“Reirradiation of the skin can be considered in the radical, adjuvant (following salvage surgery) or palliative settings in instances where the benefits of exposure to further radiotherapy have been discussed within the multidisciplinary team.” RCR document - no data about how to do it.
Anal cancer palliative RT?
30Gy/10#
Then usuals.
1L SACT carbo/taxol
2L cis/5FU
Pelvic cancers, what is considered distant metastasis?
BLADDER
PA nodes are classed as metastatic.
ANAL (+ PROSTATE)
CI or PA nodes = M1
PROSTATE
Common iliac (above bifurcation of common iliacs) and PA nodes are classed as metastatic. Some controversy re: how to treat pelvic side-wall nodes but can be treated radically.
RECTAL
CI and external iliac considered metastatic.
Inguinal considered metastatic unless tumour is below the dentate line.
CERVIX + ENDOMETRIAL
Beyond PA nodes = distant incl. inguinal or intra-abdominal nodes.
VULVAL
Anything beyond inguinal and femoral = distant.
