The document discusses cancer of the colon and rectum, including treatment options and side effects of treatment. It describes how rectal cancer is staged based on depth of penetration and lymph node involvement. Radiation therapy can help expand the surgical resection volume for some rectal cancers. The document includes images and descriptions of male and female pelvic anatomy, as well as CT, PET, and portal images related to imaging and radiation treatment planning for rectal cancer. It discusses techniques to minimize side effects of pelvic radiation and palliative uses of radiation for recurrent or metastatic disease.

2. Colon and rectal stage is based on deep penetration and lymph nodes

5. Radiation can safely expand the ‘surgical resection’ volume

6. Rectal cancers can be resected as Stage II A/B (purple) with N1 nodes but are less favorable and borderline resectable stage IIIC (red) as N2 nodes (>4) are found, stage IV are (black) metastatic. Stage 0, yellow; I, green; II, blue; III, purple; IV, red; and IV (metastatic), black. Definitions of TN on left and stage grouping on right .

7. A. Coronal. B. Sagittal (left, male; right, female). C. Transverse (left, male; right, female). (1) Right ureter. (2) Rectum. (3) External anal sphincter. (4) Middle rectal artery. (5) Left external iliac artery. (6) Roof of sigmoid mesocolon. (7) Urinary bladder. (8) Prostate. (9) Rectovesical pouch. (10) Seminal vesicle. (11) Levator ani. (12) Anal canal. (13) Internal anal sphincter. (14) Uterus. (15) Vesicouterine pouch. (16) Urethra. (17) Cervix of uterus. (18) Rectouterine pouch (of Douglas). (19) Obturator internus. (20) Prostatic venous plexus. (21) Ovary.

8. Male Anatomy (2) Rectum. (3) External anal sphincter. (4) Middle rectal artery. (5) Left external iliac artery. (6) Roof of sigmoid mesocolon. (7) Urinary bladder. (8) Prostate.(10) Seminal vesicle. (11) Levator ani. (12) Anal canal. (13) Internal anal sphincter. (16) Urethra. (17) Cervix of uterus. ( (19) Obturator internus. (20) Prostatic venous plexus.

9. Normal male anatomy

10. Female Anatomy (2) Rectum. (7) Urinary bladder. (9) Rectovesical pouch. (11) Levator ani. (12) Anal canal. (13) Internal anal sphincter. (14) Uterus. (15) Vesicouterine pouch. (16) Urethra. (17) Cervix of uterus. (18) Rectouterine pouch (of Douglas). (19) Obturator internus. (21) Ovary.

13. Rectal Cancer and Nodes Sentinel nodes of the rectum include the pelvic perirectal and sacral nodes.

14. Lymph Nodes from Colon and Rectum

16. Pelvic CT Anatomy Prostate rectum bladder

17. Bladder Prostate Rectum Pelvic CT Anatomy in Man

18. PET scan showing rectal cancer

22. CT scan is obtained at the time of simulation CT images are then imported into the treatment planning computer

23. In the simulation process the CT and PET scan images are used to create a computer plan

24. Computer generated images and the size of the radiation cloud around these structures

25. Using PET Scan to identify site of rectal cancer cancer rectum prostate pubic bone bladder small bowel

26. Computer generated images to match the PET scan

27. Original PET scan showing area of cancer Computer generated images with radiation

28. Imaging rectal cancer radiation fields Portal image (x-ray image showing the area of radiation (light blue) Computer generated radiation target (dark blue)

29. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment

30. PET scan images are used to target the areas that need radiation

31. PET scan images are used to target the areas that need radiation

32. Radiation dose clouds are tailored to the areas that are at risk

33. Side Effects of Pelvic Radiation Radiation fields Radiation may hit the small bowel causing some cramps, diarrhea and fatigue

34. Side Effects of Pelvic Radiation Radiation fields Radiation may hit the bladder and rectum causing urinary burning or frequency and rectal irritation

35. Techniques to minimize radiation side effects (hitting the small bowel) using the “belly board”

38. Case Study: Recurrent Colon Cancer with Unresectable Mesenteric Mass

39. Recurrent Mass surrounded by loops of normal bowel , so technically difficult to treat with conventional radiation cancer bowel bowel

40. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

41. Using image guided IMRT can better target the cancer and limit the dose to normal structures Radiation dose cloud Radiation dose cloud

42. Low Dose Radiation for Liver Metastases

43. Radiosurgery for Liver Mets with Cyberknife

44. Radiosurgery for Liver Mets

45. A phase I/II dose-escalation trial of Cyberknife radiation for control of primary or metastatic liver disease Early toxicity has been mild with 3 patients (13%) experiencing grade 2 or greater toxicity. In the 21 patients with >3 month follow-up, 3 (14%) have experienced a late toxicity. There have been 6 local recurrences. The lesion local recurrence rate is 17% and the patient local recurrence rate is 25%. Mean time to recurrence was 8.4 months. Conclusion: Cyberknife radiation can be delivered safely in doses up to 30 Gy in a single fraction. Accrual of long-term local control and toxicity data is ongoing.

46. Brain Mets and Radiation conventional whole brain radiation or radiosurgery (Cyberknife or Gamma knife)

47. Radiation prescription for # Diagnosis: # External radiation: # Internal radiation: #