The Use of Stereotactic Body Radiation Therapy in Gastrointestinal Malignancies in Locally Advanced and Metastatic Settings
Hematology-Oncology, Northwestern University, Chicago, IL, USA.Clinical Colorectal Cancer (Impact Factor: 2.81). 07/2010; 9(3):136-43. DOI: 10.3816/CCC.2010.n.018
Gastrointestinal (GI) malignancies are a major cause of cancer morbidity and mortality, with an estimated 275,720 cases and 135,800 deaths in 2009. Treatment of GI malignancies presents a challenge both in the localized and metastatic setting and in formulating new ways to improve local disease control and ultimately overall survival. Among conventional modalities of treatment, such as systemic chemotherapy, fractionated radiation therapy, surgical resection, and nonsurgical invasive means, a new technology has emerged: stereotactic body radiation therapy (SBRT). Its origins stem from the intracranial stereotactic radiosurgery developed in 1950s for the treatment of patients with intracranial malignancies. SBRT is a new and innovative way of delivering high-dose radiation to the extracranial tumor targets in one or few fractions with a high degree of precision. Although SBRT technology such as CyberKnife and Novalis are becoming increasingly popular and widely used, there are limited data that provide comparison with conventional therapy, and no randomized, prospective, multicenter studies that having been conducted in areas of GI malignancies. Current studies that provide data on SBRT use consist of small cohorts of patients, making any assessment of survival inadequate. This article is a technical review of SBRT and will focus on the origins and principles of SBRT, utilization of SBRT technology in local and metastatic settings in GI malignancies, and the examination of local control, median survival, and toxicities. It will review available data and will discuss future directions in the GI field.
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ABSTRACT: In this review article, we review the current literature addressing the use of stereotactic body radiation therapy (SBRT) in non-hepatobiliary gastrointestinal malignancies. For many gastrointestinal malignancies, the desire to treat large fields encompassing nodal drainage and micrometastatic disease has precluded the use of stereotactic body radiation therapy for most definitive cases. However, the use of SBRT in locally advanced pancreatic cancer (LAPC) as well as in the treatment of metastatic abdominal lymph nodes has shown excellent local control rates. In carefully selected patients, local control in LAPC has been achieved with SBRT with minimal side effects. Toxicity in these patients has most closely correlated with the dose and volume of irradiated duodenum and small bowel. Similar patterns of excellent local control with minimal side effects have also been seen in the treatment of abdominal lymph node metastases as well as gastric and rectal cancer recurrence.
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ABSTRACT: Concurrent administration of chemotherapy and radiotherapy has been increasingly used in cancer treatment, leading to improvements in survival as well as quality of life. Currently, it is a feasible preference, often regarded as the standard therapeutic option, for many locally confined solid tumors, including anal, bladder, cervical, esophageal, gastric, head and neck, lung, pancreatic and rectal cancers. In patients with these tumors, combined modality therapy improves local tumor control and survival while, in some instances, obviating the need for surgical removal of the organ of origin. The scientific rationale for the use of chemoradiation derives from the preclinical and clinical observations of synergistic interactions between radiotherapy and chemotherapy. When chemotherapy and radiotherapy are administered together, the chemotherapeutic agents can sensitize the cancer cells to the effects of ionizing radiation, leading to increased tumor-killing effects within the radiotherapy field. This, in turn, can improve local control of the primary tumor and, in some cancers, render surgical resection unnecessary. In other cases, patients with tumors that were initially considered unresectable are able to undergo curative interventions after completing chemoradiation. The chemotherapy component can address any potential micrometastatic disease that, without therapy, leads to an increased risk of distant recurrence. A large body of evidence exists that supports the use of chemoradiotherapy in gastrointestinal cancers. In fact, one of the first tumor types in which the superior efficacy of chemoradiation was described was anal cancer. Since then, chemoradiotherapy has been explored in other gastrointestinal malignancies with superior outcomes when compared with either radiation or chemotherapy alone. This article aims to recapitulate the clinical evidence supporting the use of chemoradiotherapy in a variety of gastrointestinal tumor types.
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ABSTRACT: Stereotactic body radiotherapy (SBRT) is a novel form of noninvasive, highly conformal radiation treatment that delivers a high dose to tumor. The advantage of the technique resides in its ability to provide a high dose to tumor but spare normal tissues to an extent not previously possible. In this paper we will provide an introduction and review of this technology with regard to its use in gynecologic malignancies. Preliminary results from our experience are presented for the purpose of illustrating the range of SBRT applications in gynecologic oncology. A comprehensive literature review was conducted and our experience from the past three years was reviewed. Six case series are published that report results of SBRT for gynecologic malignancies. Sixteen gynecologic patients have been treated with SBRT at our institution. Treatment sites include pelvic and periaortic nodes (9 patients), oligometastatic disease (2), and cervical or endometrial primary tumors when other conventional external radiation or brachytherapy techniques were unsuitable (5). Preliminary follow-up at a median of 11 months (range, 0.3-33 months) demonstrates 79% locoregional control, 43% distant failure, and 50% overall survival. SBRT boosts to macroscopic periaortic node recurrences and other sites seem to provide local control and a possibility of long-term disease-free survival in carefully selected patients. Previously this had been difficult to achieve with conventional radiotherapy because of the proximity of periaortic nodes to small bowel. SBRT also offers a novel approach for minimally invasive treatment in the management of gynecological cancer where current surgical and radiotherapy techniques are unsuitable.
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