Radiotherapy

Radiotherapy may be used:

  • Adjuvantly (after surgical excision)
    • Preferably chemoradiotherapy with 5-FU
    • Otherwise radiotherapy alone
  • Palliatively (for unresectable disease)
    • Preferably with chemotherapy
    • Consider brachytherapy for boost to tumour volume (needs skilled team and interested gastroenterologist/radiologist)
  • Palliative brachytherapy alone

Adjuvant Chemoradiotherapy

Pre-Simulation

Informed Consent

Always.

Special Procedures

Consider renal function scan.

Other Medical Staff

Involve medical oncologist to administer 5-FU.

Allied Health

Dietician (due to poor oral intake, nausea/vomiting from upper abdominal radiotherapy).

Simulation

Position

Prone

Immobilisation

Wing board (arms above head). Kneefix.

Bolus

Not Required

Image Acquisition

CT scan from carina to acetabulum

Motion Acquisition

Consider fluoroscopy / 4D CT to assess motion in region of interest.

Planning

Fusion

Not required

  • Volumes
    • CTVp = Tumour Bed
    • CTVn = Regional nodes
    • Perihilar: Porta hepatis, coeliac axis
    • Distal: Hepatic, pancreatoduodenal, SMA, coeliac axis
    • ITVp/n = CTV + 1 cm sup/inf (or based on fluoroscopy/4DCT)
    • PTVp/n = ITV + 0.5 cm
  • Dose
    • Two phase:
    • PTV p+n receive 45 Gy
    • 5.4 Gy boost to PTVp.
  • Organs at Risk
    • Liver < 32 Gy mean dose
    • Kidney < 18 Gy mean dose
    • Spinal cord max < 45 Gy
    • Small bowel - volume receiving > 45 Gy no larger than 195 cc
    • Stomach max < 55 Gy

Outcomes

  • Benefit - Double median survival (8-16 months)
  • Early Effects: Fatigue, nausea, vomiting, diarrhoea, skin reaction
  • Late Effects: Cosmetic skin changes, small bowel obstruction (10%), stomach ulcer (<5%), myelopathy (< 0.2%)

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