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PowerPoint Slides
Colorectal Cancer
Survivorship:
The Role of Radiation
Therapy in the Treatment
of Colorectal Cancer
English Text
Colorectal cancer Survivorship: The Role of Radiation
Therapy in the Treatment of Colorectal Cancer
VideoTranscript
Professional Oncology Education
Colorectal Cancer Survivorship: The Role of Radiation
Therapy in the Treatment of Colorectal Cancer
Time: 8:52
Daniel Malatek, PA-C
Physician Assistant
Radiation Oncology – GI Service
The University of Texas, MD Anderson Cancer Center
Hi. My name is Daniel Malatek. I’m a Physician
Assistant at the University of Texas MD Anderson
Cancer Center and I work in the Radiation Oncology
Department, GI Service. Today, we’re going to talk
about the role of radiation therapy in the treatment of
colorectal cancers.
Spanish Translation
Supervivencia al cáncer colorrectal: La función de la
radioterapia en el tratamiento del cáncer colorrectal
Transcripción del video
Educación Oncológica Profesional
Supervivencia al cáncer colorrectal: La función de la
radioterapia en el tratamiento del cáncer colorrectal
Duración: 8:52
Daniel Malatek, PA-C
Asistente Médico
Servicio de Oncología Radiológica Gastrointestinal
MD Anderson Cancer Center de la Universidad de Texas
Hola. Mi nombre es Daniel Malatek y soy asistente
médico en el Servicio de Oncología Radiológica
Gastrointestinal en el MD Anderson Cancer Center de la
Universidad de Texas. Hoy vamos a hablar del rol de la
radioterapia en el tratamiento de cánceres colorrectales.
Daniel Malatek, PA-C
Physician Assistant
Radiation Oncology – GI Service
1
Objectives
At the conclusion of this lesson, the participant will be able to:
The objectives of this lesson are [to] discuss the
foundational concepts in radiation therapy; describe how
radiation therapy is delivered; and recognize the role of
radiation therapy in the treatment of colon cancer, rectal
cancers, and recurrent colorectal cancers.
El objetivo de esta lección es analizar los conceptos
fundamentales de la radioterapia, describir cómo se aplica
la radioterapia, y reconocer la función de la radioterapia
en el tratamiento del cáncer de colon, el cáncer rectal y el
cáncer colorrectal recurrente.
There are three types of radiation therapy that are
delivered by external beam. The first is photons.
They’re high energy x-rays that are produced by linear
accelerators and the most commonly used form of energy
for treatment.
Electrons are produced by linear
accelerators as well. They have a less of a depth of
penetration so they’re only used for specific
circumstances. Protons are also an available treatment
with rad --- external beam radiotherapy. But it is only
available at a few select centers of which the University
of Texas MD Anderson Cancer Center is one.
Hay tres tipos de radioterapia que se aplican por haz
externo. El primero usa fotones, rayos X de alta energía
producidos por aceleradores lineales y la forma más
común de energía para el tratamiento. Los aceleradores
también producen electrones con menor profundidad de
penetración que se utilizan solo en casos específicos. Los
protones también se utilizan en la radioterapia de haz
externo, pero solo en unos pocos centros, como el MD
Anderson Cancer Center de la Universidad de Texas.
• Discuss foundational concepts in radiation therapy
• Describe how radiation therapy is delivered
• Recognize the role of radiation therapy in the treatment of
colon cancer, rectal cancer, and recurrent colorectal cancer
Concepts in Radiation Therapy
• External beam radiotherapy (EBRT)
– Photons – high energy x-rays produced by
linear accelerators
– Electrons – produced by linear accelerators
– Protons – available only at a few select centers; e.g.
The University of Texas MD Anderson Cancer Center
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Linear Accelerator
Radioactive Materials Used in
Radiation Therapy
• Cobalt 60 - now mostly used only in third world countries for
external beam radiation
• Cobalt is the radiation source for gamma knifes
• Side effects are the same as radiation from linear accelerators
except the side effects are usually worse
This is a picture of a linear accelerator commonly used
today and a treatment room or vault as it’s called that
patients go into to receive their treatment.
Este es un acelerador lineal de uso común hoy en día, en
una sala o bóveda donde los pacientes reciben
tratamiento.
Now, prior to linear accelerators, radiation therapy was
most commonly delivered with a radioactive source or
radioactive material of which Cobalt 60 was most
commonly used. It’s now mostly only used in third
world countries who can’t afford linear accelerators. But
it is also the radiation source for gamma knives. And we
won’t speak much about gamma knives, but they’re
specialized radiation treatment machines that can deliver
a very high dose of radiation therapy to a very small
specific area. The side effects of Cobalt 60 are the same
as radiation from linear accelerators, except the side
effects are usually worse.
Antes de los aceleradores lineales, la radioterapia se
aplicaba mediante una fuente radiactiva o materiales
radiactivos, de los cuales el cobalto 60 era el más
utilizado. Se emplea principalmente en los países del
tercer mundo que no pueden adquirir aceleradores
lineales, y es también la fuente de radiación para el
bisturí gamma. Se trata de máquinas de radioterapia
especializadas que pueden aplicar una muy alta dosis de
radioterapia en un área específica muy pequeña. Los
efectos secundarios del cobalto 60 son los mismos que en
los aceleradores lineales, aunque más intensos.
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Brachytherapy and Intraoperative
Radiotherapy (IORT)
• Placement of radioactive materials
– Either temporary or permanent
– Iridium-192 mostly used for temporary placement
Now, there’s two other ways that radiation therapy can be
delivered and that’s called brachytherapy and
intraoperative radiation therapy.
This involves the
placement of radioactive materials. This is either
temporary or permanently placed. Iridium-192 is mostly
used for temporary placement and radioactive gold,
palladium, or iodine is mostly used for permanent
placement.
Hay otras dos maneras de aplicar radioterapia:
braquiterapia y radioterapia intraoperatoria. Esto implica
la colocación de materiales radiactivos de manera
temporal o permanente. El iridio 192 se usa
principalmente para la colocación temporal, y el oro,
paladio y yodo radiactivos, para la permanente.
Here’s a picture of a radioactive seed – one there and one
there. They’re very small, less than --- or about a
millimeter in diameter.
Aquí hay una foto de dos semillas radiactivas, una aquí…
y la otra aquí. Son muy pequeñas, de alrededor de un
milímetro de diámetro.
– Radioactive gold, palladium or iodine mostly used
for permanent placement
http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation
High Dose Radiation and
Radioactive Implants
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Indications for Radiation Therapy in the
Treatment Colorectal Cancer
• Colon and rectal cancers
– Definitive treatments
Now, “What’re the indications for radiation therapy in
the treatment of colorectal cancer?” It can be used for
definitive treatments, either neo-adjuvantly or adjuvantly.
It can be used intraoperatively. It’s used for local control
of disease, treatment of recurrent cancers, and also for
palliative treatments, including metastatic lesions.
¿Cuáles son las indicaciones para la radioterapia en el
tratamiento del cáncer colorrectal? Puede utilizarse para
tratamientos definitivos, de manera neoadyuvante o
adyuvante, y también de manera intraoperatoria. Se usa
para el control local de la enfermedad, el tratamiento de
cánceres recurrentes y también para tratamientos
paliativos, incluidas las lesiones metastásicas.
Now, its role in colon cancer is limited. It’s usually
indicated when there is perforation of tumor through the
colon, if there’s an incomplete surgical resection with
tumor left behind, or a patient is not a surgical candidate.
It still will give local control of disease and it still can
treat recurrent disease. And also, again, can be used for
metastatic lesions from a colon primary.
Su función en el cáncer de colon es limitada. Por lo
general se indica cuando hay perforación del tumor a
través del colon, si hay una resección quirúrgica
incompleta con tumor remanente, o si un paciente no es
candidato para la cirugía. Aun así mantendrá el control
local de la enfermedad y permite tratar la enfermedad
recurrente. Puede utilizarse en las lesiones metastásicas
de un cáncer de colon primario.
• Neoadjuvant vs. adjuvant
• Intraoperative radiotherapy (IORT)
– For local control of disease
– Treatment for recurrence
– Palliative treatments
www.NCCN.org; NCCN GuidelinesTM
Colon Cancer Version 3.2011, Rectal Cancer Version 4.2011
Role in Colon Cancer Treatment
• Limited Role
– Perforation
– Incomplete resection
– Patients not surgical candidates
– Local control of disease
– Recurrence
– Metastatic lesions
www.NCCN.org; NCCN GuidelinesTM
Colon Cancer Version 3.2011
5
Role in Rectal Cancer Treatment
• Commonly delivered preoperatively now, but was used
postoperatively also not long ago
– Local control of disease including for recurrence
– Greater chance of tumor resection with sphincter preservation
• Adjuvantly/postoperative
– Local control
Now, for rectal cancers, radiation therapy provides a
more primary definitive role. It’s commonly delivered
preoperatively now, but, in the --- the not too distant
future, it was used postoperatively quite commonly as
well. Again, local control of disease, including for
recurrence, is obtained with radiation therapy. And it
gives the surgeon a better chance of tumor resection with
sphincter preservation at the time of surgery as well.
When it’s used postoperatively in rectal cancers, it’s used
for local control.
En el cáncer rectal, la radioterapia tiene una función más
importante y definitiva. Ahora suele aplicarse antes de la
operación, pero hasta hace poco se utilizaba
postoperatoriamente. El control local de la enfermedad,
incluida la recurrencia, se obtiene con radioterapia.
Además, ofrece al cirujano mayor probabilidad de resecar
el tumor preservando el esfínter durante la cirugía.
Cuando se usa de forma postoperatoria en el cáncer
rectal, permite el control local.
Now, the dose of radiation therapy that’s delivered when
it’s done preoperatively is a total dose of 50.4 Gray in 28
fractions. The first 45 Gray is given in 25 fractions to the
whole pelvis that’s at risk for disease, including the
lymph nodes. And then an additional 5.4 Gray boost is
given in 3 fractions to the tumor only. Again, this is for
local control and to hopefully have a better sphincter
preservation during surgery.
And then surgery is
performed approximately eight weeks after the
completion of treatments.
La dosis de radioterapia antes de la operación es un total
de 50.4 grays, en 28 fracciones. Los primeros 45 grays se
aplican en 25 fracciones en toda la pelvis en riesgo,
incluidos los ganglios linfáticos. Luego se da un refuerzo
de 5.4 grays en tres fracciones, solo al tumor, para el
control local y una mejor preservación del esfínter
durante la cirugía. Unas ocho semanas después de
finalizar los tratamientos se realiza la cirugía.
www.NCCN.org; NCCN GuidelinesTM
Rectal Cancer Version 4.2011
Rectal Cancer Treatment
• Neoadjuvantly/preoperatively
– External beam radiotherapy
• Usually total dose of 50.4 Gy in 28 fractions
• 45 Gy in 25 fractions to pelvis
• 5.4 Gy in 3 fractions to tumor only
• For local control and sphincter preservation
– Surgery performed 6 – 8 weeks after treatments
www.NCCN.org; NCCN GuidelinesTM
Rectal Cancer Version 4.2011
6
Treatment Planning for Radiation
Therapy
Intraoperative Radiation Therapy
• 10 – 15 Gy to tumor bed
– Delivered with brachytherapy
– Radiation seeds used
– Temporarily placed at site of tumor
– High dose can be delivered
This is a picture of typical radiation therapy treatment
plan, one section of it. And, the red is the tumor being
treated. The purple line is the area being treated to 45
Gray and the blue line is the area that’s getting the total
dose of 50.4 Gray.
Esta es una imagen en corte de un típico plan de
tratamiento de radioterapia. En rojo se muestra el tumor a
tratar. La línea morada es el área tratada con 45 grays, y
la línea azul es la que está recibiendo la dosis total de
50.4 grays.
Now, radiation can also be delivered inter --intraoperatively as we mentioned earlier. When done so,
10 to 15 Gray is delivered to the tumor bed. It’s
delivered with brachytherapy, radiation seeds that are
radioactive are used and they’re temporary placed at the
site of tumor. A high dose can be delivered by giving
radiation therapy this way because normal tissues can be
moved out of the way, lead shields placed to prevent
doses of radiation from getting to normal tissues which
cause side effects.
La radiación también puede aplicarse de manera
intraoperatoria. De ser así, se aplican entre 10 y 15 grays
al lecho tumoral. Es aplicada con braquiterapia,
utilizando semillas radiactivas colocadas temporalmente
en el sitio del tumor. Esto permite aplicar una alta dosis
de radioterapia desplazando los tejidos normales y
colocando protectores de plomo para evitar que la
radiación provoque efectos secundarios.
www.NCCN.org; NCCN GuidelinesTM
Rectal Cancer Version 4.2011
7
Colorectal Cancer and Radiation
Therapy
• Adjuvantly/postoperatively
– External beam
• 45 Gy in 25 fractions to the pelvis
• +/- 5.4 Gy – 9 Gy in 3 - 5 fractions to tumor bed
• Delivered 4 – 6 weeks after surgery
• For local control
Now, when used postoperatively for colorectal cancers, a
dose of 45 Gray in 25 fractions to the pelvis is usually
delivered. And then there’s an optional boost that can be
given at the discretion of the physician and then for each
patient’s particular case to a dose of 5.4 Gray up to 9
Gray that’s delivered in 3 to 5 fractions to the tumor bed.
It’s usually delivered four to six weeks after surgery once
the patient has recovered from surgery. Their incision
should be completely healed prior to starting radiation
therapy because rad --- radiation can cause delayed
wound healing. And once again, it’s used for local
control.
Cuando se usa de manera postoperatoria para el cáncer
colorrectal, suele administrarse a la pelvis una dosis de 45
grays en 25 fracciones. Según el criterio del médico y
para cada caso particular, puede administrarse al lecho
tumoral un estímulo opcional de 5.4 a 9 grays en 3 a 5
fracciones. Se realiza de cuatro a seis semanas después de
la cirugía, una vez que el paciente se ha recuperado. La
incisión debe estar curada completamente antes de
comenzar la radioterapia, ya que la radiación puede
retrasar la cicatrización de las heridas. También se utiliza
para el control local.
Now, there are special cases when radiation can be used
definitively without surgery.
However, it’s not
recommended. And the only reason you would usually
want to consider it, is if the patient was not a surgical
candidate. The radiation can be delivered either by
external beam radiation or brachytherapy.
Hay casos especiales donde la radiación puede usarse sin
necesidad de cirugía; sin embargo, no es recomendable.
La única razón por la que se consideraría es si el paciente
no fuera candidato a cirugía. La radiación se puede
administrar mediante radiación de haz externo o
braquiterapia.
www.NCCN.org; NCCN GuidelinesTM
Rectal Cancer Version 4.2011
Colorectal Cancer and Radiation
Therapy
• Definitively without surgery
– External beam or brachytherapy
• Patient not a surgical candidate
www.NCCN.org; NCCN GuidelinesTM
Rectal Cancer Version 4.2011
8
Colorectal Cancer and Radiation
Therapy
• Recurrent cancer after radiation treatments
– Few centers retreat an area of the body that has been
previously treated
• Why? greater risk of acute and late side effects
– Treatment can be with either external beam, brachytherapy
or both
– Smaller treatment fields used
– Smaller doses given and usually BID
Now, retreatment of cancer that’s reoccurred in a
radiation treatment field is usually not recommended.
The body that’s received radiation therapy always
remembers that fact and there’s a greater risk of acute and
late side effects if that area again receives radiation
therapy. However, MD Anderson Cancer Center is one
of the few centers that has been retreating patients with
great success over the past five to seven years. Treatment
can be delivered with either external beam or
brachytherapy or both. When an area that’s received
previous radiation therapy is treated, smaller treatment
fields are used to help minimize the risks of side effects,
both acute and late. Smaller doses are given and usually
the dose is --- daily dose is divided up into twice per day
fractions.
No es recomendable volver a tratar un cáncer que ha
reaparecido en un campo irradiado. El organismo
“recuerda” que ha recibido radioterapia y hay un mayor
riesgo de efectos secundarios agudos y tardíos si una
zona la recibe nuevamente. Sin embargo, el MD
Anderson Cancer Center es uno de los pocos centros que
ha vuelto a tratar exitosamente a pacientes a lo largo de
los últimos cinco a siete años. El tratamiento puede
aplicarse con haz externo, braquiterapia o ambas. Si es un
área que ya ha recibido radioterapia, se utilizan campos
de tratamiento más pequeños para minimizar el riesgo de
efectos secundarios, tanto agudos como tardíos. Son dosis
más pequeñas y por lo general la dosis diaria se divide en
dos fracciones por día.
Now, when delivered with brachytherapy again,
definitively or intraoperatively, radioactive seeds are
used. They’re placed temporarily or permanently and
temporary
seeds
are
most
commonly
used
intraoperatively, where permanent seeds are most
commonly used for unresectable tumors.
Cuando se aplica mediante braquiterapia de forma
definitiva o intraoperatoria, se utilizan semillas
radiactivas que se colocan de manera temporal o
permanente. Las semillas temporales son más utilizadas
durante la cirugía, mientras que las permanentes se usan
más en los tumores no extirpables.
Das P et al., Int J Radiat Oncol Biol Phys 2010 77(1):60
Mohiuddin M et al., Int J Radiat Oncol Biol Phys 1993 27(5):1159
Brachytherapy
• Definitive or intraoperatively
– Radioactive seeds
– Placed temporarily or permanently
– Temporary seeds most commonly used intraoperatively
– Permanent seeds most commonly used for
unresectable tumors
www.NCCN.org; NCCN GuidelinesTM
Rectal Cancer Version 4.2011
9
Summary
• Radiation therapy is an integral part of colorectal
cancer treatments
• It is usually a safe and effective treatment for local control
of tumors
So, in summary, radiation therapy is an integral part of
the treatment of colorectal cancers. It is usually a safe
and effective treatment for proven local control of
tumors. It can render tumors more amendable to
resection and reduce the risk of recurrence. In select
patients, it can be used for retreatment as well. Thank
you. This is --- is the end of my talk. And your feedback
is appreciated.
En resumen, la radioterapia es una parte integral del
tratamiento del cáncer colorrectal. Suele ser un
tratamiento seguro y eficaz para el control local
comprobado de los tumores. Puede hacer a los tumores
más factibles de resección y reducir el riesgo de
recurrencia. En ciertos pacientes, puede usarse en
segundos tratamientos. Gracias. Este es el final de mi
charla. Apreciaremos su opinión.
• It can render tumors more amendable to resection
and reduce the risk of recurrence
• In select patients can be used for retreatment
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