Radical RT for HCC dose/#?
Eligibility.
(RCR only - Solitary tumour <5cm, CPA, meets dose constraints for 3#. 45Gy/3#/alternate days.)
Eligibility: Histology or radiol (If cirrhotic and >1cm) diagnosis, unsuitable for resection, transplant, TACE or PD post RFA or TACE, max 6cm (10cm in QART), max 5 lesions (3 lesions in QART - 5 difficult in practice).
PS 0-2, CPA.
30-50Gy/5#/alternate days according to the mean liver dose that can be achieved (</= 13Gy for 50Gy, increasing to </= 16Gy for 30Gy. MLD >16Gy with 30Gy/5# = not suitable for SABR).
Use a 4DCT scan.
Patient Positioning
Patients must be immobilized in a supine position with both arms above their head, using a wingboard with headrest and SABR vacuum bag for arm support and a suitable knee support. The abdominal compression board should be used in all patients who can tolerate it.
VOLUMES.
GTV = The GTV is the visible metastases (site of disease) as visualised on the planning CT.
(HCC is typically best visualized on contrast-enhanced CT, with hyper-intensity being seen in the arterial phase and hypo-intensity being seen in the venous or delayed phases.)
Multiple GTVs are defined on the different images to give:
GTV_BH defined on 3D breath hold image (unless unable to acquire).
GTV_inhale defined on 4D inhale image.
GTV_exhale defined on GTV_exhale image.
ITV The initial ITV is produced from the combination of all the GTVs
The final ITV must encompass all tumour motion and must be checked against all 4DCT phases and extended if required.
CTV = NONE (HALL = HCC, Adrenal, Lung Lymph nodes)
PTV = ITV + 5mm
Radical retreat with SABR not permitted outside of a trial.
Met HCC 1L?
1L = atezolizumab Bevacizumab
alternatives = lenvatanib or sorafanib. Len has superior PFS and RR over soraf, same OS so is preferred.
Adjuvant biliary tract cancer radiotherapy?
For resected gallbladder and extrahepatic CCA (not IHC).
As per phase II trial: T2-T4 N+ or positive margins.
50-60Gy (1.8-2Gy#) to tumour bed and 45Gy (in 1.8Gy/# i.e. 25#) to nodes with concurrent Fpd.
E.g. 50Gy/25#/5 weeks to tumour bed with 45Gy to nodes with concurrent capecitabine.
Unresectable biliary tract cancer Radiotherapy dose/#?
1L SACT
Unresectable biliary tract Ca except gallbladder.
50.4Gy/28#/5.5 weeks
1L = Durvalumab gem/cis (or gem/cis alone)
Check FGFR2, MSI and IDH1R132 for 2L options.
Chemoradiotherapy in pancreatic cancer?
Eligibility.
Volumes.
Locally advanced pancreatic cancer (unresectable or medically unfit for surgery).
At least stable disease post induction chemo (folfirinox or Gem if less fit). Scan at 3m to assess.
PS0-1, lesion 5-6cm (max 7cm QART), no duodenal involvement.
Improves local control not OS.
50.4Gy/28#/5.5 weeks with concurrent capecitabine 830mg/m2 BD on days of RT (QART).
Adjuvant CRT, as above - occasionally considered (MDT decision) if very high risk features.
QART Immobilisation:
Patients are planned and treated in the supine position with their arms above their heads and immobilised with a wingboard and knee fix.
When patients can tolerate it an abdominal compression board will be used to reduce movement due to respiration.
Fasting: 2 hours nil by mouth prior to scan and treatment. Oral contrast to allow visualisation of upper GI structures (stomach/duodenum & small bowel) which will also be used at treatment.
4DCT scan.
Volumes:
Using 3D ExBH:
GTV_T = includes the macroscopic pancreatic tumour visible on imaging.
GTV_N = locoregional lymph nodes > 1cm in short axis diameter. Peri-tumoural node is < 1cm, can be included within if radiologist concludes that the lymph node is highly likely to be malignant.
Using 4D inhale phase and Using 4D exhale phase
Create GTV_T_ inhale and GTV_N_inhale, GTV_T_ exhale and GTV_N_exhale as per above instructions.
ITV = GTV_C = Boolean addition of all GTV (verify that the involved tumour/nodes are adequately covered on all remaining phases of 4D-CECT datasets i.e. editing to account for the motion effects seen on the remaining datasets in the 4D series).
CTV_4D = ITV+ 0.5cm in all directions.
Edit out areas of non-involved GI overlap and to include ‘at risk’ regions (not clarified what is “at risk”).
PTV_50.4_4D = CTV_4D + 0.5cm in all directions.
1L SACT met Panc
1L If other combo chemos are unsuitable and would have gem alone = Gem/abraxane (nab paclitaxel)
1L FOLFIRINOX, also can give 2L
Radical management for oesophageal SCC?
T1-T2N0 = surgery alone.
Sometimes neoadjuvant chemotherapy (SCC and Aca) – 2 cycles cisplatin and capecitabine (or 5FU) - for patients with disease not amenable to definitive or neoadjuvant CRT e.g. surgically
resectable but with nodes outside of radiotherapy field
Cisplatin 80mg/m2 D1
Capecitabine 1000mg/m2 bd D1-14
Every 21 days for 2 cycles
> /= T3N0/N+ SCC
Concurrent chemo-radiotherapy 50Gy/25#/5 weeks with concurrent cisplatin and capecitabine.
Before radiotherapy, the patient would complete 2 cycles of cisplatin 60mg/m2 IV D1 and capecitabine 625mg/m2 BD, every 21 days.
Radiotherapy would start with the 3rd cycle, 4 cycles in total.
OR
If v. fit and young and in operable distribution:
Neo-adjuvant chemo-radiotherapy as per cross trial with 41.4Gy/23#/4.5 weeks with concurrent weekly IV carbo AUC2 with paclitaxel 50mg/m2.
Either CRT then followed by surgery +/- adjuvant nivolumab if residual disease and R0 at surgery post CRT.
Definitive CRT alone considered for:
Cervical oesophageal lesion (operation very morbid) or if not fit for surgery.
Immpobilisation
Upper ⅓ oesophagus (upto 32cm as oral) - immobilised supine, arms down with an orfit shell and knee support. Middle + lower ⅓ oesophagus - supine with arms above head and a knee support. Scanned with 2mm slices, IV contrast 3D CT scan with additional 4D CT scan for distal oesophagus or GOJ tumours.
VOLUMES:
3DCT
GTVp = tumour and any involved nodes within 30mm.
GTVn = involved nodes > 30mm from primary.
CTVA = GTVp+20mm sup/inf done manually +/- GTVn + 10mm sup/inf done manually.
CTVC = CTVA + 5mm circumferential (not sup/inf) margin.
CTVB = CTVA + 10mm circumferential (not sup/inf) margin. Edit CTVB off natural barriers but leave minimum of 5mm from CTVA (i.e. edit down to CTVC at most.
PTV = CTVB + 10mm sup/inf and 5mm circumferentially.
Distal tumours:
4DCT - Contour GTVs and CTVs on 4DCT max exhale, 4DCT max inhale and 3DCT. ITV = CTVB inhale + CTVB exhale + CTVB 3D. PTV = ITV + 5mm isotropically.
Below GOJ. CTVB is extended to include all CTVn and elective nodal regions at risk. CTVB is extended 20mm below GTVp or 10mm below GTVn whichever is lower.
At risk nodal regions - include distal oesophagus, lesser curve and gastrohepatic region - see OG lec from Cardiff for some pics.
Radical Tx oesophageal, GOJ and gastric adenocarcinomas?
T1N0 = surgery alone.
> /=T2N0 as per below options.
Sometimes neoadjuvant chemotherapy (SCC and Aca) – 2 cycles cisplatin and capecitabine (or 5FU) - for
patients with disease not amenable to definitive or neoadjuvant CRT e.g. surgically
resectable but with nodes outside of radiotherapy field
Cisplatin 80mg/m2 D1
Capecitabine 1000mg/m2 bd D1-14
Every 21 days for 2 cycles.
Standard treatment is perioperative FLOT chemotherapy for T2N0 and above (T1N0
should go straight to surgery)
4 cycles q14. preoperative FLOT (5FU, leucovoin, oxaliplatin and docetaxel)
Docetaxel 50mg/m2
Oxaliplatin 85mg/m2
5FU 2600mg/m2 over 24 hours via infusor or as inpatient
Leucovorin 200mg/m2
Needs post chemo CT and review in OG MDT
4 cycles pre op and 4 cycles postoperative FLOT if fit (within 12 weeks of surgery)
Oesophageal and GOJ only.
If not suitable for peri-operative FLOT e.g. IHD, DPYD deficiency.
(SCC also - If very fit and young w SCC in operable distribution).
Neo-adjuvant chemo-radiotherapy as per cross trial with 41.4Gy/23#/4.5 weeks with concurrent weekly IV carbo AUC2 with paclitaxel 50mg/m2.
Followed by surgery +/- adjuvant nivolumab if residual disease and R0 at surgery post CRT.
Immpobilisation
Upper ⅓ oesophagus (upto 32cm as oral) - immobilised supine, arms down with an orfit shell and knee support. Middle + lower ⅓ oesophagus - supine with arms above head and a knee support. Scanned with 2mm slices, IV contrast 3D CT scan with additional 4D CT scan for distal oesophagus or GOJ tumours.
VOLUMES:
3DCT
GTVp = tumour and any involved nodes within 30mm.
GTVn = involved nodes > 30mm from primary.
CTVA = GTVp+20mm sup/inf done manually +/- GTVn + 10mm sup/inf done manually.
CTVC = CTVA + 5mm circumferential (not sup/inf) margin.
CTVB = CTVA + 10mm circumferential (not sup/inf) margin. Edit CTVB off natural barriers but leave minimum of 5mm from CTVA (i.e. edit down to CTVC at most.
PTV = CTVB + 10mm sup/inf and 5mm circumferentially.
Distal tumours:
4DCT - Contour GTVs and CTVs on 4DCT max exhale, 4DCT max inhale and 3DCT. ITV = CTVB inhale + CTVB exhale + CTVB 3D. PTV = ITV + 5mm isotropically.
Below GOJ. CTVB is extended to include all CTVn and elective nodal regions at risk. CTVB is extended 20mm below GTVp or 10mm below GTVn whichever is lower.
At risk nodal regions - include distal oesophagus, lesser curve and gastrohepatic region - see OG lec from Cardiff for some pics.
Adjuvant RT/CRT in Gastro-oesophageal cancer?
Consider in R1 resection without heavy nodal burden or mets.
Consider if less likely to benefit from chemo e.g. mandard (tumour regression grade) score of 5 = high.
45Gy/25#/5weeks with 5Fu or cape (RCR Aca chemo).
With chemo if fit enough (QART).
Radical radiotherapy oesophagus?
Immobilisation.
“A small cohort of patients may be considered unfit to receive chemoradiotherapy but fit enough to receive radical radiotherapy. Radiotherapy is given here for maximum local control as the chance of cure is extremely small.” QART
If tumour < 5cm
50Gy/16#/Daily
If tumour 5- 10cm
55Gy/20#/ 4 weeks
Immobilisation
· Cervical and upper 1/3 oesophageal tumours
Supine with arms by sides with knee support and immobilisation using an orfit shell.
· Middle and lower 1/3 tumours
Supine with arms above head with knee support.
Palliative radiotherapy oesophagus and GOJ?
1L SACT metastatic
Good PS, for longer term local control:
30Gy/10#/2weeks
40Gy/15#/3weeks (occassionally)
Standard dose = 20Gy/5#/1week
Poor Ps or bleeding 8Gy/1#
1L Aca HEr2+ Cis/FPd/Herceptin
1L Aca Her2 negative - IO cis/Fpd if pdl1 CPS >/=1%
Nivo cis cape if pdl1 CPS >/=5
Pemb if pdl1 CPS>/=1
1L Scc oesoph = IO cis/Fpd if pdl1 >/=1%, IO 2 years.
Pemb if odl1 CPS >/=10, Nivo if pdl1 >/=1%
For both (Her 2 neg), if pdl1 CPS (or not) >/=1%, then get IO with the chemo.
Trastuzumab Cycle 1 = 8mg/kg Loading dose
Cycle 2 onwards Trastuzumab 6mg/kg*
*if treatment is delayed by >7 days patients should have a further loading dose of 8mg/kg.
IV infusion Cisplatin 80mg/m2
Capecitabine 1000mg/m2 twice a day 1-14 incl
q21Max 6 x chemo, then carry on herceptin until PD
Alternrtive = 60 cis and 625 cape
Palliative radiotherapy gastric cancer?
Can be used for bleeding 20Gy/5# or 8Gy/1#. 8Gy may be preferred for less toxicity and option of re-treatment.
Palliative re-treatment oesophageal cancer?
QART.
Consider for palliative retreatment following good response to initial RT and >6mth symptomatic improvement.
20Gy/10#/2weeks.
Alternative 15Gy/5#/1week.
NB ealy dysphagia (still managing solids) + fit enough to attend, can consider pall RT.
Advanced dysphagia, stent would be better, cannot iraadiate after a stent (only consider with prolonged post-op bleeding or bleeding disorder).
