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Title: The role of palliative radiation therapy in symptomatic locally advanced gastric cancer

Abstract

Purpose: To review the outcome of palliative radiotherapy (RT) alone in patients with symptomatic locally advanced or recurrent gastric cancer. Methods and Materials: Patients with symptomatic locally advanced or recurrent gastric cancer who were managed palliatively with RT at Cancer Institute, Singapore were retrospectively reviewed. Study end points included symptom response, median survival, and treatment toxicity (retrospectively scored using the Common Toxicity Criteria v3.0 [CTC]). Results: Between November 1999 and December 2004, 33 patients with locally advanced or recurrent gastric cancer were managed with palliative intent using RT alone. Median age was 76 years (range, 38-90 years). Twenty-one (64%) patients had known distant metastatic disease at time of treatment. Key index symptoms were bleeding (24 patients), obstruction (8 patients), and pain (8 patients). The majority of patients received 30 Gy/10 fractions (17 patients). Dose fractionation regimen ranged from an 8-Gy single fraction to 40 Gy in 16 fractions. Median survival was 145 days, actuarial 12-month survival 8%. A total of 54.3% of patients (13/24) with bleeding responded (median duration of response of 140 days), 25% of patients (2/8) with obstruction responded (median duration of response of 102 days), and 25% of patients (2/8) with pain responded (median duration of responsemore » of 105 days). No obvious dose-response was evident. One Grade 3 CTC equivalent toxicity was recorded. Conclusion: External beam RT alone is an effective and well tolerated modality in the local palliation of gastric cancer, with palliation lasting the majority of patients' lives.« less

Authors:
 [1];  [2];  [3];  [2];  [3];  [4];  [2];  [3];  [2];  [2];  [3];  [2];  [2];  [3];  [5]
  1. Department of Radiation Oncology, Cancer Institute, National University Hospital (Singapore) and Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital (Singapore). E-mail: Jeremy_Tey@mail.nhg.com.sg
  2. Department of Radiation Oncology, Cancer Institute, National University Hospital (Singapore)
  3. (Singapore)
  4. (Australia)
  5. Clinical Trials and Epidemiology Research Unit, Ministry of Health (Singapore)
Publication Date:
OSTI Identifier:
20944677
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 67; Journal Issue: 2; Other Information: DOI: 10.1016/j.ijrobp.2006.08.070; PII: S0360-3016(06)02833-1; Copyright (c) 2007 Elsevier Science B.V., Amsterdam, Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; CARCINOMAS; FRACTIONATED IRRADIATION; METASTASES; PAIN; PATIENTS; RADIATION DOSES; RADIOTHERAPY; REVIEWS; SINGAPORE; STOMACH; TOXICITY

Citation Formats

Tey, Jeremy, Back, Michael F., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Shakespeare, Thomas P., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, North Coast Cancer Institute, Port Macquarie, New South Wales, Mukherjee, Rahul K., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Lu, Jiade J., Lee, Khai Mun, Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Wong, Lea Choung, Leong, Cheng Nang, Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, and Zhu Ming. The role of palliative radiation therapy in symptomatic locally advanced gastric cancer. United States: N. p., 2007. Web. doi:10.1016/j.ijrobp.2006.08.070.
Tey, Jeremy, Back, Michael F., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Shakespeare, Thomas P., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, North Coast Cancer Institute, Port Macquarie, New South Wales, Mukherjee, Rahul K., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Lu, Jiade J., Lee, Khai Mun, Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Wong, Lea Choung, Leong, Cheng Nang, Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, & Zhu Ming. The role of palliative radiation therapy in symptomatic locally advanced gastric cancer. United States. doi:10.1016/j.ijrobp.2006.08.070.
Tey, Jeremy, Back, Michael F., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Shakespeare, Thomas P., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, North Coast Cancer Institute, Port Macquarie, New South Wales, Mukherjee, Rahul K., Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Lu, Jiade J., Lee, Khai Mun, Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, Wong, Lea Choung, Leong, Cheng Nang, Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital, and Zhu Ming. Thu . "The role of palliative radiation therapy in symptomatic locally advanced gastric cancer". United States. doi:10.1016/j.ijrobp.2006.08.070.
@article{osti_20944677,
title = {The role of palliative radiation therapy in symptomatic locally advanced gastric cancer},
author = {Tey, Jeremy and Back, Michael F. and Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital and Shakespeare, Thomas P. and Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital and North Coast Cancer Institute, Port Macquarie, New South Wales and Mukherjee, Rahul K. and Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital and Lu, Jiade J. and Lee, Khai Mun and Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital and Wong, Lea Choung and Leong, Cheng Nang and Department of Radiation Oncology, Cancer Institute, Tan Tock Seng Hospital and Zhu Ming},
abstractNote = {Purpose: To review the outcome of palliative radiotherapy (RT) alone in patients with symptomatic locally advanced or recurrent gastric cancer. Methods and Materials: Patients with symptomatic locally advanced or recurrent gastric cancer who were managed palliatively with RT at Cancer Institute, Singapore were retrospectively reviewed. Study end points included symptom response, median survival, and treatment toxicity (retrospectively scored using the Common Toxicity Criteria v3.0 [CTC]). Results: Between November 1999 and December 2004, 33 patients with locally advanced or recurrent gastric cancer were managed with palliative intent using RT alone. Median age was 76 years (range, 38-90 years). Twenty-one (64%) patients had known distant metastatic disease at time of treatment. Key index symptoms were bleeding (24 patients), obstruction (8 patients), and pain (8 patients). The majority of patients received 30 Gy/10 fractions (17 patients). Dose fractionation regimen ranged from an 8-Gy single fraction to 40 Gy in 16 fractions. Median survival was 145 days, actuarial 12-month survival 8%. A total of 54.3% of patients (13/24) with bleeding responded (median duration of response of 140 days), 25% of patients (2/8) with obstruction responded (median duration of response of 102 days), and 25% of patients (2/8) with pain responded (median duration of response of 105 days). No obvious dose-response was evident. One Grade 3 CTC equivalent toxicity was recorded. Conclusion: External beam RT alone is an effective and well tolerated modality in the local palliation of gastric cancer, with palliation lasting the majority of patients' lives.},
doi = {10.1016/j.ijrobp.2006.08.070},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 2,
volume = 67,
place = {United States},
year = {Thu Feb 01 00:00:00 EST 2007},
month = {Thu Feb 01 00:00:00 EST 2007}
}
  • Pancreatic cancer remains associated with an extremely poor prognosis. Surgical resection can be curative, but the majority of patients present with locally advanced or metastatic disease. Treatment for patients with locally advanced disease is controversial. Therapeutic options include systemic therapy alone, concurrent chemoradiation, or induction chemotherapy followed by chemoradiation. We review the evidence to date regarding the treatment of locally advanced pancreatic cancer (LAPC), as well as evolving strategies including the emerging role of targeted therapies. We propose that if radiation is used for patients with LAPC, it should be delivered with concurrent chemotherapy and following a period of inductionmore » chemotherapy.« less
  • Purpose/Objective: Palliative radiation therapy represents an important treatment option among patients with advanced cancer, although research shows decreased use among older patients. This study evaluated age-related patterns of palliative radiation use among an elderly Medicare population. Methods and Materials: We identified 63,221 patients with metastatic lung, breast, prostate, or colorectal cancer diagnosed between 2000 and 2007 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Receipt of palliative radiation therapy was extracted from Medicare claims. Multivariate Poisson regression analysis determined residual age-related disparity in the receipt of palliative radiation therapy after controlling for confounding covariates including age-related differences inmore » patient and demographic covariates, length of life, and patient preferences for aggressive cancer therapy. Results: The use of radiation decreased steadily with increasing patient age. Forty-two percent of patients aged 66 to 69 received palliative radiation therapy. Rates of palliative radiation decreased to 38%, 32%, 24%, and 14% among patients aged 70 to 74, 75 to 79, 80 to 84, and over 85, respectively. Multivariate analysis found that confounding covariates attenuated these findings, although the decreased relative rate of palliative radiation therapy among the elderly remained clinically and statistically significant. On multivariate analysis, compared to patients 66 to 69 years old, those aged 70 to 74, 75 to 79, 80 to 84, and over 85 had a 7%, 15%, 25%, and 44% decreased rate of receiving palliative radiation, respectively (all P<.0001). Conclusions: Age disparity with palliative radiation therapy exists among older cancer patients. Further research should strive to identify barriers to palliative radiation among the elderly, and extra effort should be made to give older patients the opportunity to receive this quality of life-enhancing treatment at the end of life.« less
  • Stereotactic body radiation therapy (SBRT) achieves excellent local control for locally advanced pancreatic cancer (LAPC), but may increase late duodenal toxicity. Volumetric-modulated arc therapy (VMAT) delivers intensity-modulated radiation therapy (IMRT) with a rotating gantry rather than multiple fixed beams. This study dosimetrically evaluates the feasibility of implementing duodenal constraints for SBRT using VMAT vs IMRT. Non–duodenal sparing (NS) and duodenal-sparing (DS) VMAT and IMRT plans delivering 25 Gy in 1 fraction were generated for 15 patients with LAPC. DS plans were constrained to duodenal D{sub max} of<30 Gy at any point. VMAT used 1 360° coplanar arc with 4° spacingmore » between control points, whereas IMRT used 9 coplanar beams with fixed gantry positions at 40° angles. Dosimetric parameters for target volumes and organs at risk were compared for DS planning vs NS planning and VMAT vs IMRT using paired-sample Wilcoxon signed rank tests. Both DS VMAT and DS IMRT achieved significantly reduced duodenal D{sub mean}, D{sub max}, D{sub 1cc}, D{sub 4%}, and V{sub 20} {sub Gy} compared with NS plans (all p≤0.002). DS constraints compromised target coverage for IMRT as demonstrated by reduced V{sub 95%} (p = 0.01) and D{sub mean} (p = 0.02), but not for VMAT. DS constraints resulted in increased dose to right kidney, spinal cord, stomach, and liver for VMAT. Direct comparison of DS VMAT and DS IMRT revealed that VMAT was superior in sparing the left kidney (p<0.001) and the spinal cord (p<0.001), whereas IMRT was superior in sparing the stomach (p = 0.05) and the liver (p = 0.003). DS VMAT required 21% fewer monitor units (p<0.001) and delivered treatment 2.4 minutes faster (p<0.001) than DS IMRT. Implementing DS constraints during SBRT planning for LAPC can significantly reduce duodenal point or volumetric dose parameters for both VMAT and IMRT. The primary consequence of implementing DS constraints for VMAT is increased dose to other organs at risk, whereas for IMRT it is compromised target coverage. These findings suggest clinical situations where each technique may be most useful if DS constraints are to be employed.« less
  • Purpose: To evaluate the rate of gastrointestinal (GI) toxicity of neoadjuvant chemoradiation with capecitabine, oxaliplatin, and intensity modulated radiation therapy (IMRT) in cT3-4 rectal cancer. Methods and Materials: Patients with localized, nonmetastatic T3 or T4 rectal cancer <12 cm from the anal verge were enrolled in a prospective, multi-institutional, single-arm study of preoperative chemoradiation. Patients received 45 Gy with IMRT in 25 fractions, followed by a 3-dimensional conformal boost of 5.4 Gy in 3 fractions with concurrent capecitabine/oxaliplatin (CAPOX). Surgery was performed 4 to 8 weeks after the completion of therapy. Patients were recommended to receive FOLFOX chemotherapy after surgery. The primary endpoint ofmore » the study was acute grade 2 to 5 GI toxicity. Seventy-one patients provided 80% probability to detect at least a 12% reduction in the specified GI toxicity with the treatment of CAPOX and IMRT, at a significance level of .10 (1-sided). Results: Seventy-nine patients were accrued, of whom 68 were evaluable. Sixty-one patients (89.7%) had cT3 disease, and 37 (54.4%) had cN (+) disease. Postoperative chemotherapy was given to 42 of 68 patients. Fifty-eight patients had target contours drawn per protocol, 5 patients with acceptable variation, and 5 patients with unacceptable variations. Thirty-five patients (51.5%) experienced grade ≥2 GI toxicity, 12 patients (17.6%) experienced grade 3 or 4 diarrhea, and pCR was achieved in 10 patients (14.7%). With a median follow-up time of 3.98 years, the 4-year rate of locoregional failure was 7.4% (95% confidence interval [CI]: 1.0%-13.7%). The 4-year rates of OS and DFS were 82.9% (95% CI: 70.1%-90.6%) and 60.6% (95% CI: 47.5%-71.4%), respectively. Conclusion: The use of IMRT in neoadjuvant chemoradiation for rectal cancer did not reduce the rate of GI toxicity.« less