Comparación clínica de radioterapia de intensidad modulada versus radioterapia 3D en tratamiento neoadyuvante del cáncer de recto localmente avanzado
DOI:
https://doi.org/10.56969/oc.v23i1.64Palabras clave:
IMRT, 3DRT, neoadyuvancia, cáncer de recto localmente avanzado, neoadjuvant, locally advanced rectum cancerResumen
El objetivo de este trabajo fue comparar ventajas potenciales de la radioterapia de intensidad modulada (IMRT) vs. la radioterapia 3D (3DRT) en el control loco-regional y la toxicidad aguda en pacientes con cáncer de recto localmente avanzado (CRLA).
Se analizaron retrospectivamente 235 pacientes con adenocarcinoma de recto T2/T4 y N0/N1 sometidos a radioquimioterapia neoadyuvante entre febrero de 2010 y agosto de 2015. La modalidad radiante se correlacionó con los resultados clínicos (control local y a distancia) y las tasas de toxicidades agudas urinarias, hematológicas, gastrointestinales (GI) y dérmicas.
Ciento cuarenta (59.6%) recibieron IMRT y 95 (40.4%) 3DRT. La mediana de seguimiento fue de 36 meses. Las tasas de recidiva local y metástasis a distancia fueron similares entre IMRT y 3DRT. No se encontraron diferencias estadísticamente significativas en control local (CL) ni en supervivencia global (SG) entre IMRT y 3DRT (p=0.56 y p=0.24, respectivamente), ni en colostomía libre para tumores rectales bajos (p=0.44). IMRT implicó menor toxicidad cutánea (p<0.001), hematológica (p<0.0001), urinaria (p=0.0017), y gastrointestinal (p=0.0006). La incidencia de diarrea grado ≥ 3 fue del 16% entre los pacientes del grupo 3DRT frente al 5% de del grupo IMRT.
En el análisis univariado, el estadio clínico T, edad, KPS, y quimioterapia adyuvante se asociaron con mejor SG (todos p<0.05) y la dosis total de radiación se asoció con mejor período libre de enfermedad (p=0.0065)
Postulamos que IMRT permitiría un aumento de dosis en forma segura con el potencial de aumentar la tasa de respuestas patológicas
completas (RPC), en particular en tumores rectales bajos.
Citas
Aschele C, Cionini L, Lonardi S, et al. Primary tumor response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal cancer: pathologic results of the STAR-01 randomized phase III trial. J Clin Oncol 2011; 29:2773-80. DOI: https://doi.org/10.1200/JCO.2010.34.4911
Gérard JP, Azria D, Gourgou-Bourgade S, et al. Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced rectal cancer: results of the phase III trial ACCORD 12/0405-Prodige 2. J Clin Oncol 2010; 28:1638-44. DOI: https://doi.org/10.1200/JCO.2009.25.8376
O’Connell MJ, Colangelo LH, Beart RW, et al. Capecitabine and oxaliplatin in the preoperative multimodality treatment of rectal cancer: surgical end points from National Surgical Adjuvant Breast and Bowel Project trial R-04. J Clin Oncol 2014; 32:1927-34. DOI: https://doi.org/10.1200/JCO.2013.53.7753
Wong SJ, Winter K, Meropol NJ, et al. Radiation Therapy Oncology Group 0247: a randomized Phase II study of neoadjuvant capecitabine and irinotecan or capecitabine and oxaliplatin with concurrent radiotherapy for patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2012; 82:1367-75. DOI: https://doi.org/10.1016/j.ijrobp.2011.05.027
Hong TS, Moughan J, Garofalo MC, et al. NRG Oncology Radiation Therapy Oncology Group 0822: a phase 2 study of preoperative chemoradiation therapy using intensity modulated radiation therapy in combination with capecitabine and oxaliplatin for patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2015; 93:19-36. DOI: https://doi.org/10.1016/j.ijrobp.2015.05.005
Samuelian JM, Callister MD, Ashman JB, Young-Fadok TM, Borad MJ, Gunderson LL, et al. Reduced acute bowel toxicity in patients treated with intensity-modulated radiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 2012; 82:1981-7. DOI: https://doi.org/10.1016/j.ijrobp.2011.01.051
Parekh A, Truong MT, Pashtan I, et al. Acute gastrointestinal toxicity and tumor response with preoperative intensity modulated radiation therapy for rectal cancer. Gastrointest Cancer Res 2013; 6:137-43.
Myerson RJ, Garofalo MC, El Naqa I, et al. Elective clinical target volumes for conformal therapy in anorectal cancer: a radiation therapy oncology group consensus panel contouring atlas. Int J Radiat Oncol Biol Phys 2009; 74:824-30. DOI: https://doi.org/10.1016/j.ijrobp.2008.08.070
Mangeaud A, Elías Panigo D. RMedic. En: http://www.r- medic.com/#addRef; consultado el 01/03/2017
Baglan KL, Frazier RC, Yan D, Huang RR, Martinez AA, Robertson JM. The dose-volume relationship of acute small bowel toxicity from concurrent 5-FU-based chemotherapy and radiation for rectal cancer. Int J Radiat Oncol Biol Phys 2002; 52: 176-83. DOI: https://doi.org/10.1016/S0360-3016(01)01820-X
Robertson JM, Lockman D, Yan D, Wallace M. The dose- volume relationship of small bowel irradiation and acute grade 3 diarrhea during chemoradiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 2008; 70:413-8. DOI: https://doi.org/10.1016/j.ijrobp.2007.06.066
Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004; 351:1731-40. DOI: https://doi.org/10.1056/NEJMoa040694
Bosset JF, Collete L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006; 355:1114-23. DOI: https://doi.org/10.1056/NEJMoa060829
Blaszkowsky LS, Ryan DP, Szymonifka J, et al. Phase I/II study of neoadjuvant bevacizumab, erlotinib, and 5-fluorouracil with concurrent external beam radiation therapy in locally advanced rectal cancer. Ann Oncol 2014; 25:121-6. DOI: https://doi.org/10.1093/annonc/mdt516
Kim TH, Chie EK, Kim DY, et al. Comparison of the belly board device method and the distended bladder method for reducing irradiated small bowel volumes in preoperative radiotherapy of rectal cancer patients. Int J Radiat Oncol Biol Phys 2005; 62:769-75. DOI: https://doi.org/10.1016/j.ijrobp.2004.11.015
Beriwal S, Jain SK, Heron DE, de Andrade RS, Lin CJ, Kim H. Dosimetric and toxicity comparison between prone and supine position IMRT for endometrial cancer. Int J Radiat Oncol Biol Phys 2007; 67:485-9. DOI: https://doi.org/10.1016/j.ijrobp.2006.08.067
Drzymala M, Hawkins MA, Henrys AJ, Bedford J, Norman A, Tait DM. The effect of treatment position, prone or supine, on dose-volumen histograms for pelvic radiotherapy in patients with rectal cancer. Br J Radiol 2009; 82:321-7. DOI: https://doi.org/10.1259/bjr/57848689
Freedman GM, Meropol NJ, Sigurdson ER, et al. Phase I trial of preoperative hypofractionated intensity-modulated radiotherapy with incorporated boost and oral capecitabine in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2007; 67:1389-93. DOI: https://doi.org/10.1016/j.ijrobp.2006.11.017
Zhu J, Gu W, Lian P, et al. A phase II trial of neoadjuvant IMRT-based chemoradiotherapy followed by one cycle of capecitabine for stage II/III rectal adenocarcinoma. Radiat Oncol 2013; 8:130. DOI: https://doi.org/10.1186/1748-717X-8-130
Ballonoff A, Kavanagh B, McCarter M, et al. Preoperative capecitabine and accelerated intensity-modulated radiotherapy in locally advanced rectal cancer: a phase II trial. Am J Clin Oncol 2008; 31: 264-70. DOI: https://doi.org/10.1097/COC.0b013e318161dbd3
Fleming TR. One-sample multiple testing procedure for phase II clinical trials. Biometrics 1982; 38:143-51. DOI: https://doi.org/10.2307/2530297
Descargas
Publicado
Cómo citar
Número
Sección
Categorías
Licencia
Esta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-SinDerivadas 4.0.
