What Are the Dose-Volume Constraints to Reduce Late Toxicity?

  • Krzysztof Bujko


A reduction of the risk of late postradiation toxicity is a key issue in the current debate on the indications for preoperative radiotherapy. The objective of this chapter is to provide readers with a proposal of modifying currently recommended clinical target volume (CTV) boundaries in order to diminish the risk of postradiation late side effects. Preoperative radiation increases slightly the risk of non-cancer death and the risk of small bowel obstruction. Lowering cranial border of the CTV to the S2–S3 interface may reduce this toxicity. Preoperative radiation increases the risk of anorectal and sexual function impairment in patients undergoing anterior resection and the risk of perineal wound healing delay in patients undergoing abdomino-perineal resection. Adequate location of the caudal border of the CTV may reduce this toxicity. The sphincters’ complex, the caudal part of the vagina, the penile bulb and the perineal skin should be avoided in CTV delineation, provided these regions are not invaded by a distal cancer extension. Examples of CTV contouring are provided.


Clinical Target Volume Preoperative Radiation Circumferential Resection Margin Ischiorectal Fossa Perineal Skin 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Birgisson H, Påhlman L, Gunnarsson U et al (2005) Occurrence of second cancers in patients treated with radiotherapy for rectal cancer. J Clin Oncol 23:6126–6131PubMedCrossRefGoogle Scholar
  2. 2.
    Birgisson H, Påhlman L, Gunnarsson U et al (2008) Late gastrointestinal disorders after rectal cancer surgery with and without preoperative radiation therapy. Br J Surg 95:206–213PubMedCrossRefGoogle Scholar
  3. 3.
    Blomqvist L, Glimelius B (2008) The ‘good’, the ‘bad’, and the ‘ugly’ rectal cancers. Acta Oncol 47:5–8PubMedCrossRefGoogle Scholar
  4. 4.
    Bujko K, Bujko M, Pietrzak L (2007) Clinical target volume for rectal cancer: in regard to Roels et al. (Int J Radiat Oncol Biol Phys 2006;65:1129–1142). Int J Radiat Oncol Biol Phys 68:313 (letter)PubMedCrossRefGoogle Scholar
  5. 5.
    Colorectal Cancer Collaborative Group (2001) Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet 358(9290):1291–1304CrossRefGoogle Scholar
  6. 6.
    Eriksen MT, Wibe A, Haffner J et al (2007) Prognostic groups in 1,676 patients with T3 rectal cancer treated without preoperative radiotherapy. Dis Colon Rectum 50:156–167PubMedCrossRefGoogle Scholar
  7. 7.
    Fisch BM, Pickett B, Weinberg V et al (2001) Dose of radiation received by the bulb of the penis correlates with risk of impotence after three-dimensional conformal radiotherapy for prostate cancer. Urology 57:955–959PubMedCrossRefGoogle Scholar
  8. 8.
    Frykholm GJ, Glimelius B, Pahlman L (1993) Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and evaluation of late secondary effects. Dis Colon Rectum 36:564–572PubMedCrossRefGoogle Scholar
  9. 9.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery – the clue to pelvic recurrence? Br J Surg 69:613–616PubMedCrossRefGoogle Scholar
  10. 10.
    Hermann RM, Henkel K, Christiansen H et al (2005) Testicular dose and hormonal changes after radiotherapy of rectal cancer. Radiother Oncol 75:83–88PubMedCrossRefGoogle Scholar
  11. 11.
    Kim TH, Kim DY, Cho YH et al (2005) Comparative analysis of the effect of belly board and bladder distention in preoperative radiotherapy in rectal cancer. Strahlenther Onkol 181:601–605PubMedCrossRefGoogle Scholar
  12. 12.
    Lange MM, den Dulk M, Bossema ER et al (2007) Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial. Risk factors for faecal incontinence after rectal cancer treatment. Br J Surg 94:1278–1284PubMedCrossRefGoogle Scholar
  13. 13.
    Marijnen CA, Kapiteijn E, van de Velde CJ (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20:817–825PubMedCrossRefGoogle Scholar
  14. 14.
    Marijnen CAM, van de Velde CJ (2005) Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of multicenter randomized trial. J Clin Oncol 23:1847–1858PubMedCrossRefGoogle Scholar
  15. 15.
    Myerson RJ, Garofalo MC, El Naqa I et al (2009) 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 74:824–830PubMedCrossRefGoogle Scholar
  16. 16.
    NCCN Guidelines (2011) Rectal cancer, Version 1.2012. Accessed 26 Sept 2011
  17. 17.
    Nelson H, Petrelli N, Carlin A et al (2001) National Cancer Institute Expert Panel. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93:583–596PubMedCrossRefGoogle Scholar
  18. 18.
    Nijkamp J, Kusters M, Beets-Tan RG et al (2011) Three-dimensional analysis of recurrence patterns in rectal cancer: the cranial border in hypofractionated preoperative radiotherapy can be lowered. Int J Radiat Oncol Biol Phys 80:103–110PubMedCrossRefGoogle Scholar
  19. 19.
    Nijkamp J, Doodeman B, Marijnen C et al (2012) Bowel exposure in rectal cancer IMRT using prone, supine, or a belly board. Radiother Oncol 102(1):22–29PubMedCrossRefGoogle Scholar
  20. 20.
    Peeters KCMJ, van de Velde CJ, Leer JWH (2005) Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients - A Dutch Colorectal Cancer Group Study. J Clin Oncol 23:6199–6206PubMedCrossRefGoogle Scholar
  21. 21.
    Roach M 3rd, Nam J, Gagliardi G et al (2010) Radiation dose-volume effects and the penile bulb. Int J Radiat Oncol Biol Phys 76(3 Suppl):S130–S134, ReviewPubMedCrossRefGoogle Scholar
  22. 22.
    Roels S, Duthoy W, Haustermans K et al (2006) Definition and delineation of the clinical target volume for rectal cancer. Int J Radiat Oncol Biol Phys 65:1129–1142PubMedCrossRefGoogle Scholar
  23. 23.
    Sauer R, Becker H, Hohenberger W (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740PubMedCrossRefGoogle Scholar
  24. 24.
    Stephens RJ, Thompson LC, Quirke P et al (2010) Impact of short-course preoperative radiotherapy for rectal cancer on patients’ quality of life: data from the Medical Research Council CR07/National Cancer Institute of Canada Clinical Trials Group C016 randomized clinical trial. J Clin Oncol 28:4233–4239PubMedCrossRefGoogle Scholar
  25. 25.
    Sebag-Montefiore D, Stephens RJ, Steele R et al (2009) Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet 373:811–820PubMedCrossRefGoogle Scholar
  26. 26.
    Syk E, Torkzad MR, Blomqvist L et al (2008) Local recurrence in rectal cancer: anatomic localization and effect on radiation target. Int J Radiat Oncol Biol Phys 72:658–664PubMedCrossRefGoogle Scholar
  27. 27.
    Taylor FG, Quirke P, Heald RJ et al (2011) Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg 253:711–719PubMedCrossRefGoogle Scholar
  28. 28.
    van Gijn W, Marijnen CA, Nagtegaal ID et al (2011) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol 12:575–582PubMedCrossRefGoogle Scholar
  29. 29.
    Vordermark D, Schwab M, Ness-Dourdoumas R et al (2003) Association of anorectal dose-volume histograms and impaired fecal continence after 3D conformal radiotherapy for carcinoma of the prostate. Radiother Oncol 69:209–214PubMedCrossRefGoogle Scholar
  30. 30.
    Yau I, Vuong T, Garant A et al (2009) Risk of hypogonadism from scatter radiation during pelvic radiation in male patients with rectal cancer. Int J Radiat Oncol Biol Phys 74:1481–1486PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of RadiotherapyMaria Sklodowska-Curie Memorial Cancer CentreWarsawPoland

Personalised recommendations