Skip to main content

Advertisement

SpringerLink
Log in

Reduced acute and late toxicities with intensity-modulated radiation therapy compared to three-dimensional conformal radiation therapy in post-operative gastric cancer

  • Original Research
  • Published:
Journal of Radiation Oncology

Abstract

Objective

The role of intensity-modulated radiation therapy (IMRT) in post-operative gastric cancer is unknown. We evaluated the toxicity profiles of post-operative gastric cancer patients treated with IMRT or three-dimensional conformal radiation therapy (3D-CRT).

Methods

We identified patients with gastric cancer treated with post-operative radiation at our institution between 2002 and 2016. Acute and late toxicities were evaluated per RTOG/EORTC Radiation Toxicity Grading Scale. Statistical analysis was performed using Chi-square tests, t tests, log-rank, and logistic regression.

Results

We identified 66 patients who underwent surgical resection as part of planned definitive treatment. Eighty percent of patients had T3 or higher disease, while 67% had N2+ disease.

Thirty patients received 3D-CRT, while 36 received IMRT. Patients receiving 3D-CRT were younger in age than IMRT, treated longer ago, and did not receive neoadjuvant chemotherapy.

Acute grade 2 lower GI toxicity was higher with 3D-CRT (40% vs 17%, p = 0.04). 3D-CRT had higher rates of late lung toxicity of any grade (23% vs 3%, p = 0.02), grade 3+ late esophageal toxicity (23% vs 3%, p = 0.02), and grade 2+ late intestinal toxicity (19% vs 0% p = 0.01).

Dosimetric analysis showed that keeping Bowel V5 ≤ 93% protected against development of acute lower GI toxicity of any grade, with V5 ≤ 93% resulting in 10.5% incidence, and V5 > 93% resulting in 52% incidence (p = 0.004).

Conclusions

Use of IMRT in post-operative gastric cancer is associated with reduced acute and late toxicities. Consideration should be given for prospective evaluation in the future.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Ferlay J, Shin H-R, Bray F, Forman D, Mathers C, Parkin DM (2010) Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 127:2893–2917. https://doi.org/10.1002/ijc.25516

    Article  CAS  PubMed  Google Scholar 

  2. Gunderson LL, Sosin H (1982) Adenocarcinoma of the stomach: areas of failure in a re-operation series (second or symptomatic look) clinicopathologic correlation and implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 8:1–11

    Article  CAS  PubMed  Google Scholar 

  3. Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, Haller DG, Ajani JA, Gunderson LL, Jessup JM, Martenson JA (2001) Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345:725–730. https://doi.org/10.1056/NEJMoa010187

    Article  CAS  PubMed  Google Scholar 

  4. Lee J, Lim DH, Kim S, Park SH, Park JO, Park YS, Lim HY, Choi MG, Sohn TS, Noh JH, Bae JM, Ahn YC, Sohn I, Jung SH, Park CK, Kim KM, Kang WK (2012) Phase III trial comparing Capecitabine plus cisplatin versus Capecitabine plus cisplatin with concurrent Capecitabine radiotherapy in completely resected gastric Cancer with D2 lymph node dissection: the ARTIST trial. J Clin Oncol 30:268–273. https://doi.org/10.1200/JCO.2011.39.1953

    Article  CAS  PubMed  Google Scholar 

  5. Cunningham D, Allum WH, Stenning SP, Thompson JN, van de Velde C, Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley RE, Verma M, Weeden S, Chua YJ, MAGIC Trial Participants (2006) Perioperative chemotherapy versus surgery alone for Resectable gastroesophageal Cancer. N Engl J Med 355:11–20. https://doi.org/10.1056/NEJMoa055531

    Article  CAS  PubMed  Google Scholar 

  6. NCCN: Gastric Cancer (2018) Practice Guidelines in Oncology. https://www.nccn.org/professionals/physician_gls/pdf/gastric.pdf. Accessed 01 July 2018

  7. Ringash J, Perkins G, Brierley J, Lockwood G, Islam M, Catton P, Cummings B, Kim J, Wong R, Dawson L (2005) IMRT for adjuvant radiation in gastric cancer: a preferred plan? Int J Radiat Oncol 63:732–738. https://doi.org/10.1016/j.ijrobp.2005.03.013

    Article  Google Scholar 

  8. Wieland P, Dobler B, Mai S, Hermann B, Tiefenbacher U, Steil V, Wenz F, Lohr F (2004) IMRT for postoperative treatment of gastric cancer: covering large target volumes in the upper abdomen: a comparison of a step-and-shoot and an arc therapy approach. Int J Radiat Oncol 59:1236–1244. https://doi.org/10.1016/j.ijrobp.2004.02.051

    Article  Google Scholar 

  9. Wang X, Li G, Zhang Y, Bai S, Xu F, Wei Y, Gong Y (2013) Single-arc volumetric-modulated arc therapy (sVMAT) as adjuvant treatment for gastric cancer: Dosimetric comparisons with three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). Med Dosim 38:395–400. https://doi.org/10.1016/j.meddos.2013.04.007

    Article  PubMed  Google Scholar 

  10. Li Z, Zeng J, Wang Z, Zhu H, Wei Y (2014) Dosimetric comparison of intensity modulated and volumetric arc radiation therapy for gastric cancer. Oncol Lett 8:1427–1434. https://doi.org/10.3892/ol.2014.2363

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ma H, Han J, Zhang T, Ke Y (2013) Comparison of dosiology between three dimensional conformal and intensity-modulated radiotherapies (5 and 7 fields) in gastric cancer post-surgery. J Huazhong Univ Sci Technol Med Sci 33:759–764. https://doi.org/10.1007/s11596-013-1193-9

    Article  Google Scholar 

  12. Zhang T, Liang Z-W, Han J, Bi JP, Yang ZY, Ma H (2015) Double-arc volumetric modulated therapy improves dose distribution compared to static gantry IMRT and 3D conformal radiotherapy for adjuvant therapy of gastric cancer. Radiat Oncol 10:114. https://doi.org/10.1186/s13014-015-0420-x

    Article  PubMed  PubMed Central  Google Scholar 

  13. Lohr F, Dobler B, Mai S, Hermann B, Tiefenbacher U, Wieland P, Steil V, Wenz F (2003) Optimization of dose distributions for adjuvant locoregional radiotherapy of gastric cancer by IMRT. Strahlenther Onkol 179:557–563

    Article  PubMed  Google Scholar 

  14. Milano MT, Garofalo MC, Chmura SJ, Farrey K, Rash C, Heimann R, Jani AB (2006) Intensity-modulated radiation therapy in the treatment of gastric cancer: early clinical outcome and dosimetric comparison with conventional techniques. Br J Radiol 79:497–503. https://doi.org/10.1259/bjr/43441736

    Article  CAS  PubMed  Google Scholar 

  15. Chung HT, Lee B, Park E, Lu JJ, Xia P (2008) Can all centers plan intensity-modulated radiotherapy (IMRT) effectively? An external audit of Dosimetric comparisons between three-dimensional conformal radiotherapy and IMRT for adjuvant Chemoradiation for gastric Cancer. Int J Radiat Oncol 71:1167–1174. https://doi.org/10.1016/j.ijrobp.2007.11.040

    Article  Google Scholar 

  16. Dahele M, Skinner M, Schultz B, Cardoso M, Bell C, Ung YC (2010) Adjuvant radiotherapy for gastric Cancer: a Dosimetric comparison of 3-dimensional conformal radiotherapy, Tomotherapy® and conventional intensity modulated radiotherapy treatment plans. Med Dosim 35:115–121. https://doi.org/10.1016/j.meddos.2009.03.003

    Article  PubMed  Google Scholar 

  17. Liu G-FF, Bair RJ, Bair E, Liauw SL, Koshy M (2014) Clinical outcomes for gastric Cancer following adjuvant Chemoradiation utilizing intensity modulated versus three-dimensional conformal radiotherapy. PLoS One 9:e82642. https://doi.org/10.1371/journal.pone.0082642

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Trip AK, Nijkamp J, van Tinteren H, Cats A, Boot H, Jansen EPM, Verheij M (2014) IMRT limits nephrotoxicity after chemoradiotherapy for gastric cancer. Radiother Oncol 112:289–294. https://doi.org/10.1016/j.radonc.2014.08.039

    Article  PubMed  Google Scholar 

  19. Chopra S, Agarwal A, Engineer R, Dora T, Thomas B, Sonawone S, Paul SN, Kannan S, Patil P, Mehta S, Shrivastava SK (2015) Intensity modulated radiation therapy (IMRT) is not superior to three-dimensional conformal radiation (3DCRT) for adjuvant gastric radiation: a matched pair analysis. J Cancer Res Ther 11:623–629. https://doi.org/10.4103/0973-1482.150438

    Article  CAS  PubMed  Google Scholar 

  20. Minn AY, Hsu A, La T et al (2010) Comparison of intensity-modulated radiotherapy and 3-dimensional conformal radiotherapy as adjuvant therapy for gastric cancer. Cancer 116:3943–3952. https://doi.org/10.1002/cncr.25246

    Article  PubMed  Google Scholar 

  21. Edge SB, American Joint Committee on Cancer (2010) AJCC cancer staging manual. Springer

  22. Songun I, Putter H, EM-K K et al (2010) Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 11:439–449. https://doi.org/10.1016/S1470-2045(10)70070-X

    Article  PubMed  Google Scholar 

  23. Xu D, Huang Y, Geng Q, Guan Y, Li Y, Wang W, Yuan S, Sun X, Chen Y, Li W, Zhou Z, Zhan Y (2012) Effect of lymph node number on survival of patients with lymph node-negative gastric Cancer according to the 7th edition UICC TNM system. PLoS One 7:e38681. https://doi.org/10.1371/journal.pone.0038681

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Cats A, Jansen EPM, van Grieken NCT, Sikorska K, Lind P, Nordsmark M, Meershoek-Klein Kranenbarg E, Boot H, Trip AK, Swellengrebel HAM, van Laarhoven HWM, Putter H, van Sandick JW, van Berge Henegouwen MI, Hartgrink HH, van Tinteren H, van de Velde CJH, Verheij M, van Coevorden F, Vanhoutvin S, Hulshof MCCM, Loosveld OJL, ten Tije A(B)J, Erdkamp FLG, Warmerdam FARM, van der Peet DL, Verheul HMW, Boerma D, Los M, Slot A, Houtsma D, Portielje JEA, Blaisse RJB, Spillenaar Bilgen EJ, Polée MB, Geenen MM, Braak JPBM, Neelis KJ, Slingerland M, Jansen RLH, Buijsen J, Beeker A, Eijsbouts QAJ, van Riel JMGH, Rozema T, van Spronsen DJ, Meerum Terwogt JM, Tanis BC, van der Torren-Conze AME, van Hilligersberg R, Koopman M, den Boer MO, Creemers GJ, van der Sangen M, Rentinck MEM, van den Berg HP, Jonkers GJPM, Grootenboers D, Vulink AJE, Hovenga S, van der Mijle HCJ, Baars A, Haringhuizen AW, Appels MIE, Rietbroek RC, Hendriksen EM, Legdeur MCJC, ten Bokkel Huinink D, van Dobbenburgh OA, Smit JM, van Bochove A, Veldhuis GJ, Muller EW, Bonenkamp J(H)J, Braam PM, de Boer J, van Halteren HK, Valster FAA, Imholz ALT, van Dijk MA, van der Gaast A, Otten J(H)MMB, Ceha HM, Glimelius B, Lagerbäck C, Perman M, Johnsson A, Borg D, Nielsen NH, Piwowar A, Elmlund M, Hörberg H, Edlund P, Johansson B, Flygare P, Jespersen ML (2018) Chemotherapy versus chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): an international, open-label, randomised phase 3 trial. Lancet Oncol 0:616–628. https://doi.org/10.1016/S1470-2045(18)30132-3

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA

    Ashwin Shinde, Wei-Hsien Hou, Chunhui Han, Scott Glaser, Jeffrey Wong & Yi-Jen Chen

  2. Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA

    Joseph Chao

  3. Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA

    Yanghee Woo

Authors
  1. Ashwin Shinde
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wei-Hsien Hou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Chunhui Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Scott Glaser
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joseph Chao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yanghee Woo
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jeffrey Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yi-Jen Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yi-Jen Chen.

Ethics declarations

Funding

This study received no funding.

Conflicts of interest

All authors declare that they have no conflicts of interest. Ashwin Shinde declares that he has no conflicts of interest. Wei-Hsien Hou declares that he has no conflicts of interest. Chunhui Han declares that he has no conflicts of interest. Scott Glaser declares that he has no conflicts of interest. Yanghee Woo declares that she has no conflicts of interest. Joseph Chao declares that he has no conflicts of interest. Jeffrey Wong declares that he has no conflicts of interest. Yi-Jen Chen declares that he has no conflicts of interest.

Ethical approval

This article does not contain any studies with animals performed by any of the authors. All procedures performed were in accordance with ethical standards of the institutional review board and consistent with the 1964 Helsinki declaration and its later amendments.

Informed consent

Individualized patient consent for this retrospective review was waived by the institutional review board due to the difficulty with reaching this patient population, as most had either passed away or were lost to follow-up.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shinde, A., Hou, WH., Han, C. et al. Reduced acute and late toxicities with intensity-modulated radiation therapy compared to three-dimensional conformal radiation therapy in post-operative gastric cancer. J Radiat Oncol 8, 73–80 (2019). https://doi.org/10.1007/s13566-019-00374-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13566-019-00374-2

Keywords

Search

Navigation