Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
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Michael Bassetti, MD, Ph.D. from the University of Wisconsin Carbone Cancer Center discusses all you need to know about radiation. Dr. Bassetti will talk about what radiation treatment is, how it’s used for rectal and colon cancer patients, how to prepare for treatment, how to manage side effects and more.
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Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
- 1. Radiation Treatment for CRC: How it works and what to expect Our webinar will begin shortly. WELCOME! #CRCWebinar
- 2. • Speaker: Michael Bassetti, MD, PhD • Archived Webinars: FightCRC.org/webinars • AFTER THE WEBINAR: Expect an email with links to the material & a survey. If you fill it out, we’ll send you an “I booty” bracelet • Follow along via Twitter – use the hashtag #CRCWebinar be part of the dialog and tweet- up Today’s Webinar:
- 3. @FightCRC | FightCRC.org Webinar tech: • The side control panel can be adjusted using the Orange Arrow • Questions are asked by opening the Questions tab – the arrow opens the box • Not all questions are addressed during the presentation depending on time and quantity but if necessary will be followed up individually • If you are new to GoToWebinar and experience streaming problems you should shut down other high bandwidth services such as Facebook, IM or hangout systems during presentation • The Audio tab allows you to select either your computer or phone to listen.
- 4. Resources:
- 5. Disclaimer: The information and services provided by Fight Colorectal Cancer are for general informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnoses or treatment. If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the nearest emergency room. Fight Colorectal Cancer never recommends or endorses any specific physicians, products or treatments for any condition.
- 6. Speaker: Dr. Bassetti is an Assistant Professor in the Department of Human Oncology at the UW School of Medicine and Public Health and a member of the UW Carbone Cancer Center. He sees patients at UW Carbone Cancer Center. Dr. Bassetti is a broadly trained radiation oncologist with specialty focus on patents with gastrointestinal (GI) cancers (esophagus, stomach, colorectal region, liver and pancreas). He brings expertise in the use of 3D conformal radiation, intensity modulated radiation and stereotactic ablative radiation therapy. He is committed to multidisciplinary cancer care and the advancement of clinical trials.
- 7. Radiation in the Treatment of Rectal and Colon Cancer Michael Bassetti MD PhD University of Wisconsin Assistant Professor of Radiation Oncology
- 8. • Radiation treatment basics • Rectal cancer treatment • Metastatic Colorectal Cancer – Lungs, liver, brain • Future Directions – MRI guided treatment and response – Immunotherapy in colorectal cancer Overview
- 9. Oncology (Cancer Medicine) Medical Oncology Surgical Oncology Radiation Oncology Chemotherapy Surgery Radiation Coordination of care between all the specialties often leads to the best outcomes, but also exposure to the risks of the different treatments.
- 10. Radiation Therapy • High energy “x-rays” aimed at the location of the tumor. • x-rays damage the cancer cells DNA causing them to die.
- 11. Radiation in Colorectal Cancer Care • Rectal cancer treatment • Metastatic colorectal cancer treatment – Stereotactic Radiation for spread of colorectal cancer (metastasis) to the liver, lung, or other organs
- 12. Radiation in Colorectal Cancer Care • Rectal cancer treatment • Metastatic colorectal cancer treatment – Stereotactic Radiation for spread of colorectal cancer (metastasis) to the liver, lung, or other organs
- 13. Anal Sphincter Preserving Surgery
- 14. Anatomy • Schematic • MRI
- 15. Anal Sphincter Sacrificing Surgery: This patient will require a permanent colostomy
- 16. Proximity to Anal Sphincter • Far • Close
- 17. Treatment Paradigm for Rectal Cancer Chemoradiation 5.5 wks radiation and capecitibine (or 5-FU) Surgery Temporary vs Permanent Colostomy Chemotherapy ~4 months (FOLFOX)6-10 wks 3-4 wks
- 18. • Decrease the chance of a recurrence near the rectum or in the adjacent lymph nodes • Organ preservation: Decrease the chance of an operation requiring a permanent colostomy • Less toxicity from chemoradiation if done prior to surgery Benefits of Chemoradiation before Surgery
- 19. • Intensity Modulation lets us control the shape of the radiation dose better than ever before • Improved quality of imaging both before treatment and now during treatment with Magnetic Resonance Image (MRI) guided Radiation Modern Radiation
- 20. Viewray inc
- 21. Radiation Treatment Plan • Treat the rectum, tissue around rectum and at risk lymph nodes • Avoid the hips, bladder, bowel and other tissues • 5-6 weeks of daily (M-Fri) radiation
- 22. • Decreases chance of local recurrence after surgery by half • Organ preservation: avoid a permanent colostomy – One out of every five patients felt to need a permanent colostomy was able to have avoid it • Less toxicity if radiation is done prior to surgery • Modern radiation may decrease toxicity in Conclusions: Radiation before Surgery
- 23. • Are there situations where we could avoid radiation? • Do I really need to have a permanent colostomy? • These are questions being currently investigated Current Questions
- 24. Great Response! Mass et al, Journal of Clinical Oncology 2011
- 25. Non-Operative Management? • Can some patients avoid surgery that requires a permanent colostomy? • Maybe? No Randomized Data. Long term data from Brazil, MSKCC, and prospective data from Netherlands support this may be possible in highly selected patients Habr-Gama et al, journal of Gastrointestinal Surgery, 2006 Mass et al, Journal of Clinical Oncology 2011 Smith et al, Annals of Surgery, 2012
- 26. Non-Operative Management? Chemoradiation 8-12 wks Evaluate response Complete Response Incomplete Response Surgery Very Close Surveillance Chemotherapy before or after
- 27. Can the lowest risk patients avoid radiation? Schrag et al, JCO 2014
- 28. Can I Avoid Radiation? Chemoradiation >20% response < 20% response SurgeryFOLFOX x6 Surgery FOLFOX FOLFOX Favorable Patients are randomized
- 29. Conclusions • Chemoradiation decreases pelvic recurrences, optimizes chances of anal sphincter preserving surgery. • Omission of radiation and/or surgery are both unanswered questions. These are currently being investigated in randomized clinical trials in appropriate risk patients
- 30. Curable Stage IV Disease? Surgery Stereotactic Radiation Bae et al, JSO 2010Tepper et al, JCO 2003 • Surgical series show 20-40% 10 yr survival when all metastatic disease to liver or lungs can be resected.
- 32. CRC Liver Metastasis SBRT plan
- 33. 6 months post treatment 6.2 cm 0.8 cm
- 34. Prospective Trial Control Rates Rusthoven et al, JCO 2009
- 35. Colorectal Brain Metastasis Tumor Swelling
- 36. Radiation of Resection cavity
- 37. Response At presentation 10 months post Tx Asymptomatic and doing well. Continues on FOLFOX for lung disease
- 38. Lung Radiation • This patient underwent rectal surgery and partial liver resection and multiple recurrences. • Did not tolerate FOLFOX • Recurrence in lung and nearby mediastinal lymph node not amenable to surgery
- 39. Lung Radiation
- 40. Lung Radiation Before Treatment 1.5 years after treatment
- 41. • Stereotactic Radiation is an effective treatment option for metastatic colorectal patients to varying sites. – Non-invasive – Well tolerated – Very effective Conclusions
- 42. MRI Guided Radiation The ViewRay MRIdian system is a radiation treatment system with MRI image guidance 7/12/2017 University of Wisconsin–Madison 42
- 43. Under the covers 7/12/2017 University of Wisconsin–Madison 43 Treatment gantry MRI gantry Mark Geurts
- 44. Comparison Standard Daily Pretreatment imaging MRI Improves Visualization Non MRI Daily Image MRI Daily Image
- 45. Stereotactic Ablative Liver Metastasis Radiation Radiation is only on when tumor is in proper position Contrast used to highlight the tumor and allow daily tracking Unique to be able to see and track actual tumor (not a surrogate) in realtime MRI Tracking During Treatment Anterior posterior Lung Liver Radiation Tumor Superior Inferior
- 46. Summary • Advantages of MRI Guided Radiation • Soft Tissue Resolution • Improved alignment/targeting • Confidence using high dose near critical organs • Motion management –Breath hold and Tracking • Decreased normal tissue/increase tumor dose • Improve image quality • Intra-treatment Response Assessment
- 48. Curable Stage IV Disease? • 20-40% 10 yr survival when all metastatic disease to liver or lungs can be resected. • SBRT also shows potential for long term survival in unresectable patients • Unfortunately, most patients still fail! • How can we improve?Tepper et al, JCO 2003
- 49. Immune Checkpoint Inhibition nzmu.co.nx Anti-PD-1 antibody T-cell TumorCell Release the Brakes!
- 50. High Mutational Burden Cancers Respond to Immunotherapy Highly Mutated cancers respond to Immune Checkpoint (PD-1) Inhibition How can we move this curve up here?
- 51. Radiation Effects on Tumor Microenvironment • New Mutations Created • New Antigens Expressed • Dying Tumor Cells • Release Antigens • Pro-Inflammatory Cytokines • Chemokines to attract immune cells • Remove Immunosupressive Immune Cells • Macrophages, Regulatory T-cells
- 52. SBRT and immunotherapy in colorectal cancer patients with liver confined metastasis and completely resectable disease. Dustin Deming MD Michael Bassetti MD PhD
- 53. Eligibility Patients with microsatellite stable metastatic colorectal cancer with the treatment goal of eradicating all known sites of disease will be enrolled. Patients may have had other treatments prior to enrollment, including chemotherapy, radiation or operations
- 54. Schema FDGPET/MRI FLTPET/CT FDGPET/MRI FLTPET/CT FDGPET/MRI FLTPET/CT FDG shows metabolism FLT shows proliferation
- 56. Conclusions • Radiation can stimulate a T cell response in colorectal tumors • The trial is using this response with an immune checkpoint inhibitor to attempt to help the body recognize the CRC as foreign and attack it. • Surgery after SBRT to clear any remaining metastasis and give immune therapy best chance to work against remaining possible microscopic cancer cells
- 57. Conclusions • Radiation plays an important role in localized rectal cancer management • Stereotactic radiation is an effective, non- invasive option for treatment of metastatic lesions. • MRI guided radiation allows accurate treatment and easy assessment of intra-treatment response for individually tailored radiation therapy • Immotherapy is very exciting, but currently ineffective for the majority of CRC patients. We are currently looking for ways to help the
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