Stereotactic/hypofractionated body radiation therapy as an effective treatment for lymph node metastases from colorectal cancer: an institutional retrospective analysis.

BJR Received: 6 June 2017 © 2017 The Authors. Published by the British Institute of Radiology Revised: 10 August 2017 Accepted: 23 August 2017 https://doi.org/10.1259/bjr.20170422 Cite this article as: Franzese C, Fogliata A, Comito T, Tozzi A, Iftode C, Clerici E, et al. Stereotactic/hypofractionated body radiation therapy as an effective treatment for lymph node metastases from colorectal cancer: an institutional retrospective analysis. Br J Radiol 2017; 90: 20170422. full paper Stereotactic/hypofractionated body radiation therapy as an effective treatment for lymph node metastases from colorectal cancer: an institutional retrospective analysis 1 Ciro Franzese, MD, 1Antonella Fogliata, MSc, 1Tiziana Comito, MD, 1Angelo Tozzi, MD, Cristina Iftode, MD, 1Elena Clerici, MD, 1Davide Franceschini, MD, 1Pierina Navarria, MD, 1 Anna Maria Ascolese, MD, 1Lucia Di Brina, MD, 1Fiorenza De Rose, MD, 1Giuseppe R D'Agostino, MD, 1,2 Luca Cozzi, PhD and 1,2Marta Scorsetti, MD,Prof 1 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy 2 Address correspondence to: Antonella Fogliata E-mail: Objective: The colorectal cancer (CRC) might present loco-regional recurrence, including lymph-node metastasis. Stereotactic body radiotherapy (SBRT) is a non-invasive and well-tolerated ablative treatment. Aim of the present study is to evaluate efficacy and toxicity of SBRT with volumetric modulated arc therapy (VMAT) in this setting. Methods: 35 patients presenting a total of 47 nodal recurrences from CRC, treated with VMAT-SBRT from 2008 to 2015, were selected. About three fourth of the treatments delivered 45 Gy in 6 daily fractions. End-points were the detection of toxicities, overall survival (OS), local control (LC), disease progression free incidence (DPFI) and disease free survival (DFS). Tumour response was assessed according to the RECIST criteria. Results: Only Grade 1 and 2 toxicities were recorded. Median follow-up was 15 months (range 2–68). Local relapse was reported in 6 patients, regional relapse in 10 patients. Complete remission was reported in 20 cases (53%), partial remission in 14 (37%). Rates of LC at 1, 2 and 3 years were 85.3, 75.0 and 75.0%, respectively. At 1 year the actuarial OS was 100%, at 2 and 3 years was 81.4%. Median DFS was estimated in 16 months, with an incidence of 69.4, 33.3 and 19.4% at 1, 2 and 3 years, respectively. Conclusion: The use of the VMAT-SBRT in lymph-node recurrence of CRC could prevent severe complications and achieve satisfying rates of disease control. Advances in knowledge: The use of VMAT-SBRT is a viable approach for lymph-node recurrence of CRC. Introduction Colorectal cancer (CRC) is the third most common cause of cancer-related death worldwide.1 Even if the management of CRC has continued to evolve during the last century, approximately 20–50% of patients will develop recurrence after definitive treatment for primary tumour.2–4 was described as oligometastatic state for the first time by Hellman and Weichselbaum.6 It can be considered an intermediate state between local disease and widespread disease, and could be still amenable of a local treatment. Lateral pelvis (LPLN) and paraortic lymph node (PALN) can be site of metastases from CRC. While PALN are considered as M1 stage by the American Joint Committee for Cancer (AJCC),7 LPLN are considered regional lymph nodes. Kobayashi et al8 demonstrated that the risk of lymph node metastases to the LPLN is about 16.5% in T3 and 37.2% in T4 disease. Lower is the risk of PALN, with an overall incidence of 1.7%.9 Although liver and lung resection in oligometastatic CRC is recognized as an effective approach, surgical dissection of lymph node metastasis is not widely accepted due to the lack of clinical evidence and to the high post-operative morbidity. The improvement of both surgical techniques and of radiotherapy (RT) and chemotherapy approaches, decreased the rate of local recurrence to 4–8%.5 However, the risk of loco-regional and distant metastases still persist. Recurrences from CRC often present as solitary disease or a limited number of metastases.3 This pattern of recurrence Franzese et al BJR The improvement in the last decades of the RT treatments increased the possibility to approach on isolated metastatic foci with stereotactic body radiation therapy (SBRT). SBRT is a non-invasive and well-tolerated ablative treatment, and its role in oligometastatic CRC has been extensively investigated. Hoyer et al10 published the results of a phase II study investigating the role of SBRT in oligometastatic CRC patients. 64 patients with a total number of 141 lesions were enrolled (44 in the liver, 12 in the lungs, 3 lymph nodes, 1 adrenal gland and 4 in two organs) and after 2 years, actuarial local control (LC) was 86 and 63% in tumour and patient based analysis, respectively. We previously published our experience with the use SBRT and volumetric modulated arc therapy (VMAT) for the treatment of abdominal lymph node metastases from different histologies. We included 71 patients with a total of 79 lesions, treated with a dose of 45 Gy delivered in 6 daily fractions of 7.5 Gy each. In our analysis disease control was achieved in 97.5% of the lesions with an actuarial LC rate at 1 year of 83%.11 Few reports describe the role of SBRT specifically for the treatment of lymph node metastases in oligometastatic CRC. One of the first data were published by Kim et al.12 They only included 7 patients with PALN recurrence, and the reported 1- and 3-year overall survival (OS) rates were 100 and 71.4%, respectively. Aim of the present study is to evaluate the efficacy and pattern of toxicity of SBRT with VMAT for the treatment of lymph node metastasis in oligometastatic CRC patients. Table 1. Patient and treatment characteristics No. of patients 35 No. of treatments 38 No. of lesions 47 Age Median, range (y.o.) 66, 32–89 Sex Male 24 Female 11 Median, range (months) 15, 2–68 Colon 26 Rectum 9 Solitary 17 Follow-up Primary tumour Type of nodal metastasis Site of nodal metastasis Inclusion criteria were: no more than three lymph node metastases; maximum diameter 5 cm on CT or MRI scan; no evidence of progressive or untreated gross disease outside the lymph node; no concurrent chemotherapy, interrupted at least 1 week before; primary tumour was resected or under control; other sites of metastatic disease, different from lymph node, were accepted if amenable of ablative treatment or surgery. Minimum age 18 years old. Patients were excluded if the lesions were bigger than 5 cm in maximum diameter; if the lesions were treated with other local approaches or if they had other abdominal illnesses that contraindicate RT, as inflammatory bowel disease or bowel ulcers. Three of those patients (males) were treated for different nodal r (...truncated)