Rectal Cancer

Ashley Coffey

Epidemiology
3rd most common in men and women
9 out of 10 patients are 50+ years old
About 1 in 20 of men and women will be diagnosed with
colon/rectal cancer in their lifetime
8.6% of all cancer deaths
Dropping

64.7% will survive in 5 years

More than one million survivors

Etiology
High fat and low fiber diet
Genetics
Polyps
Inflammatory Bowel Disease
Chronis colitis
Crohns Disease

Older age, smoking, drinking, diabetes

Signs and Symptoms

Change in bowel habits
Diarrhea, constipation, change in stool

Blood in stool
Abdominal discomfort
Change in appetite
Weight loss
Fatigue

Diagnostic Tests
Digital rectal exam
Sigmoidoscopy
Colonoscopy
Barium Enema
Biopsy
Carcinoembryonic antigen assay
Amount of protein in blood

Anatomy

Anatomy

Lymph Node

Lymph Drainage

Histopathology
>90% are adenocarcinoma
Carcinoid
Leiomyosarcoma
Lymphoma
Squamous cell

Staging
Can be AJCC or Dukes Staging

Rectal Wall

Metastatic Sites
Local structures of pelvis
Liver
Most common

Lung
Bone

Common Treatment
Stage 1: surgery
Typically through anus

Stage 2 and 3: pre-op RT and chemo, surgery,

post-op chemo
Commonly 5 FU

Stage 4: depends on spread but includes a

combination of all three treatments

Radiation Therapy
Supine or Prone
3 field or IMRT
PA, Right Lat, Left Lat
Wedges (60 degrees)

Total pelvis to 4500cGy

Boost to total of 5040cGy 5400cGy

TD 5/5
Bladder 65 Gy
Small bowel 45 Gy
Rectum 60 Gy
Femoral Heads 52 Gy
Spinal cord 47 Gy

Side Effects
Acute

Chronic

Diarrhea

Persistent diarrhea

Abdominal cramping &

bloating

Proctitis

Bloody discharge
Dysuria

Urinary incontinence
Bladder atrophy
Damage to small bowel
Obstruction

Targeted Therapy
Hard to explore due to uniqueness of cancer
Few biomarkers considered tied to GI cancers
Chromosome arm 18q deletion, EGFR/KRAS mutations

IV injections every 1-3 weeks

Studies still searching for better methods that will result in
effective results
So far, questionable results with increased toxicity
5-FU provides more benefits for genetic mutations and
overall health

Targeted Therapy
Bevacizumab
Slows vascular endothelial growth
Growth of new blood vessels
Paired with 5-FU
First approved in 2004 with metastatic colorectal cancers

Cetuximab and panitumumad

Stops epidermal growth
Overexpression results in cancers
KRAS mutation makes ineffective (4/10)
Paired with 5-FU

Targeted Therapy Side Effects

Bevacizumab
High blood pressure

Cetuximab/
Panitumumab

Bleeding

Skin problems
Rash, acne
Skin peeling
Can lead to infection

Low WBC counts

Headache

Headache

Fatigue

Fatigue

Mouth sores
Diarrhea

Fever
Diarrhea

VMAT: Arc Therapy

Each arc 360 degrees
6MV with max dose rate of 600 MU/min
PTV and OAR outlined: bladder, small bowel, femur
heads
Compared to 7 field IMRT plan
Single Arc
Double Arc
Clockwise and counterclockwise

VMAT Advantages
Single Arc
Target dose coverage comparable to IMRT
Better V95 and V107

Double Arc
Highest minimum PTV and lowest max dose
Most homogeneous
No difference in bladder dose

Lower MU and treatment times

VMAT Disadvantages
Both increase healthy tissue irradiated
V5 and V10 worse than IMRT
V20 better than IMRT

Both increase dose to femur heads

Single
Increase V40 and V50 of bladder

Double
Increased V15 of small bowel by 55cc

VMAT Side Effects

Only one acute side effect reported
Diarrhea
Grade 1-2: 40%
Grade 3: 8%

Best treatment option

3 field or IMRT would still be the best option
Less normal tissue irradiated
Less dose to the OARs and target volume still covered

VMAT carried no remarkable results over IMRT

Targeted therapy presents more problems with less results

Survival
Stage

5 Year Survival

74%

IIA

65%

IIB

52%

IIC

32%

IIIA

74%

IIIB

45%

IIIC

33%

IV

6%

Citations
Advances in radiotherapy and targeted therapies for rectal cancer. (n.d.).
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885997/
American Cancer Society. (n.d.). Colon/Rectum Cancer. Retrieved from
http://www.cancer.org/cancer/colonandrectumcancer/indexmayoclinic
Fung-Kee-Fung SD. Therapeutic approaches in the management of locally
advanced rectal cancer. J Gastrointest Oncol 2014;5(5):353-361. doi: 10.3978/
j.issn.2078-6891.2014.067
Mayo Clinic. (n.d.). Rectal cancer - Diseases and Conditions - Mayo Clinic.
Retrieved from
http://www.mayoclinic.org/diseases-conditions/rectal-cancer/basics/definition/
con-20036554
Shang et al.: VMAT planning study in rectal cancer patients. Radiation Oncology
2014 9:219.