Rectal CA - dose in inoperable ca or where pt refuses tme/apr?

[medgator]

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How high do you guys go? NCCN suggests >54 Gy.

I've got a lady who underwent transanal excision, found to be pathologic T3N0 with close margins/lvi.
Refuses further surgery, already did the whole discussion about SOC in this situation etc. Will refer to med onc to discuss xeloda vs 5-FU during treatment.

 

[seper]

I've treated gross disease in the rectum up to 61.2 Gy. Some people would even do cylinder HDR (not me). In your case, after tumor has been removed, 55.8 Gy may suffice.

 

[RadOncDoc21]

I'm being extremely lazy, but isn't there data to support cCR in select patients who either refused or couldn't have surgery and a good number did ok with salvage surgery for recurrences.

 

[napoleondynamite]

I'm being extremely lazy, but isn't there data to support cCR in select patients who either refused or couldn't have surgery and a good number did ok with salvage surgery for recurrences.

Yah there's a randomized trial looking at treating the cCR's more like anal with close surveillance and surgical salvage

 

[Palex80]

59.4 Gy is as far as we usually go.

 

[Neuronix]

Plenty of retrospective data, here's one review by Habr-Gama (Brazil) who does a lot of this:

http://www.ncbi.nlm.nih.gov/pubmed/20883957 (this does 50.4 Gy, they have a smaller series doing 54 Gy + 5-FU/LV)

There is a lot of nuance to this. Note, the Habr-Gama protocol includes rigid proctoscopy every 1 -2 months for the first year. Success with this protocol (i.e. long-term disease control) is not great. We're talking on the order of 25% - 33% depending on the series.

At my current institution, we'd probably do an HDR brachytherapy boost after 50.4 Gy (http://www.ncbi.nlm.nih.gov/pubmed/22592048). Few institutions do it.

NCCN recommends adjuvant FOLFOX s/p resection of a T3N0 cancer. In this setting it's a bit unclear, but I'd probably recommend it for another 5 months. The data is a bit nuanced on this point to my recollection. You can look at the staging (I hope you have a solid MRI or EUS) and I'd have a low threshold to call small mesorectal nodes N+ to further justify chemo (particularly in a T3 +LVI the risk is high anyway).

 

[medgator]

Thanks for the input guys, going to go with 55.8 Gy + Xeloda, it's basically been "debulked"

 

[Neuronix]

Yeah transanal in a T3 is basically a big biopsy. If you re-image the patient, there will very likely still be gross disease. I'm kinda surprised the margins aren't positive.

 

[medgator]

Yeah transanal in a T3 is basically a big biopsy. If you re-image the patient, there will very likely still be gross disease. I'm kinda surprised the margins aren't positive.

It was borderline t2/t3 on the pelvic mr as well the eus. Imaging suggested it was around 3 cm which is close to the pathologic size of 2.7 cm. I'll see what my planning CT shows