HSC 340 12-19-10

Gastrointestinal Cancer

Genitourinary Cancer

Gynecological Cancer

Gastrointestinal Cancer

• Esophagus

• Stomach

• Pancreas

• Rectum

• Anus

Esophageal Cancer

• Usually squamous cell

• Males more than females

• Cure rates <10%

• Accounts for 1% of all US cancers

Esophageal Anatomy

• Cervical esophagus

• Upper thoracic

• Middle thoracic

• Lower thoracic

Esophageal routes of spread

• Spreads longitudinally through lymphatics– Upper– Middle– Lower

Esophageal CA Treatment

• Surgery only- poor control

• External beam only- curative and palliative

• Chemo, radiation

• Chemo, radiation & surgery

• Curative vs. Palliative

Esophageal Radiation Therapy Techniques

• Cervical Esophagus– Lateral opposed, Obliques

• Thoracic Esophagus– AP:PA, Obliques or AP:PA & Obliques

combo

Esophageal Immobilization & Positioning Devices

• Prone sometimes used to pull esophagus away from sc.

• Supine more common

• Arms above head, may-be hard to hold if elderly

• Vac-lok, body casts

• *problems w/arms at sides…3 pt set-up

Esophageal Doses

• Palliative– 30 Gy over two weeks to 50 Gy over five weeks

• Preoperative + chemo– 30 Gy over three weeks to 45 Gy over five weeks

• No surgery– Above dose with a boost to 60-65 Gy

• HDR and LDR are options….

Stomach Cancer

• Majority Ulcerative Adenocarcinomas

• High incidence in Japan

Stomach Anatomy

• Begins at Gastroesophageal Junction and ends at pylorus

• Many critical structures surrounding organ

Stomach CA Routes of Spread

• Direct Extension

• Widespread

Stomach CA Treatment

• Surgery & Post-op Radiation Therapy with Concurrent chemo

• Radiation alone in palliative cases (unresectable)

Stomach Radiation Therapy Techniques

• AP:PA

• Doses:– 40-45 Gy w/ 5FU– Boost to 50-55Gy if needed

Stomach Immobilization and Positioning

• Supine

• Arms above head

• Vac-lok, body cast

• Contrast?

Pancreatic Cancer

• Ductal adenocarcinoma

• Occur in the head of pancreas

Pancreas Anatomy

• Three sections– Head, tail, body– L1-L2

Pancreatic CA routes of spread

• Direct extension

• Lymphatics

Pancreatic CA Treatment

• Surgery (you want the cancer in the tail!)

• Surgery, Post-op Radiation Therapy, Combination Chemotherapy

• Unresectable tumors- palliative radiation therapy and chemotherapy

Pancreatic radiation therapy techniques

• Three field (AP, Lats), four field (AP:PA, Lats), IGRT –couch rotation used to create unique fields that spare structures

• Doses– 45-50 Gy with combo chemo

– Limit lateral fields to 18-20Gy to preserve kidneys

– 60 Gy in 3 two week courses (20 Gy/week) for palliative with field reduction @ 45 Gy

Pancreatic Immobilization & Positioning

• Supine

• Arms above head

• Vac-lok, alpha cradle, body cast

• Contrast- swallowed and/or injected (to see kidneys)

Rectal Cancer

• Adenocarcinomas

• Men = Women

• Rectal bleeding

• 2nd most common cause of CA death in US

Rectal Anatomy

• 13-15 cm long

• Upper, middle and lower valves divide into sections

Rectal CA routes of spread

• Direct extension

• Wide spread dissemination

Rectal CA Treatment

• Surgery

• Surgery + Radiation Therapy + Chemo

• Pre-op, post-op, pre-op & post-op

Rectal CA Radiation Therapy

• Three field (PA and lats) patient prone

• IGRT

• Doses– 45 Gy– May boost to 50Gy

Rectal Immobilization and Positioning

• Prone

• Belly board (to help “drop” small bowel)

• Arms above head

• Contrast- Oral for sm. Bowel, rectal

• Rectal marker

• Anal marker

• Vaginal marker

Anal Cancer

• Squamous cell

• 3cm in length

Anal CA Routes of Spread

• Direct Extension, Lymphatics, Blood stream

Anal CA Treatment

• Surgery

• Chemo and Radiation

Anal CA Radiation Therapy

• AP:PA, IGRT

• Doses– 45 Gy with Chemo– Boost to 50-55 Gy if large tumor– 60-65 Gy radiation only– e- beams may be used if inguinal nodes have

disease

Anal CA Immobilization and Positioning

• Supine

• Vac-lok, body cast

• Marker on lowest pt. of tumor

• Vaginal marker

Genitourinary Cancer

• Bladder

• Prostate

Bladder Cancer

• Blood in urine

• Cigarette smoke common cause

• Transitional cell carcinoma

Bladder CA Routes of Spread

• Direct Extension

• Lymphatics

Bladder CA Radiation Therapy

• Radiation therapy alone

• Surgery & Radiation Therapy

• Surgery, Chemo & Radiation Therapy

• 3 most common:– Preop radiation followed by cystectomy– Radiation after transurethral resection– Transurethral resection, chemo, radiation

Bladder CA Radiation Therapy Techniques

• Four field technique, IGRT

• Dose:– Pre-op 45-50Gy– No chemo, no surgery 45-50 Gy with a boost to

65-70 Gy– Trials

Bladder CA Immobilization & Positioning

• Supine

• Contrast- Bladder (air introduced to see anterior surface of bladder)

• Arms on chest

Prostate Cancer

• Most common cancer in men

• Adenocarcinoma

• 60+

• PSA, Gleason Score

Prostate CA Routes of Spread

• Local invasion

• Lymphatics

• Bone

Prostate CA Treatments

• Observation

• Radical Prostatectomy

• Implant Therapy

• External Therapy

• Combination Implant & External

• Hormone Therapy for Metastatic disease

Prostate CA Radiation Therapy Techniques

• Four field, IGRT

• Doses:– 75-81Gy with conedown off rectum if possible– Post-op 60-66 Gy

Prostate CA Positioning and Immobilization

• Supine/Prone (study done)

• Vac-lok

• Arms on chest holding ring

• Contrast- bladder, nodal, rectal**, sm. Bowel

Gynecological Cancer

• Uterine Cervix

Uterine Cervix

• Squamous cell

• Incidence of Invasive CA decrease due to PAP smear detection

Uterine Cervix Routes of Spread

• Direct extension

• Lymphatics

Uterine Cervix Treatment

• Surgery (TAH)

• Radiation Therapy (external & implant)

• Surgery, Radiation Therapy, Chemo

Uterine Cervix Radiation Therapy Treatment

• Four field to 40-45Gy

• Boost intercavitary

Uterine Cervix Positioning and Immobilization

• Anal marker

• Rectal barium

• Vaginal marker

• Bladder contrast

• Prone w/belly board to move sm.bowel