23. Anal Cancer - The GEC-ESTRO Handbook of Brachytherapy

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Anal Cancer

THE GEC ESTROHANDBOOKOF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 01/03/2023

TABLE 3 TREATMENT OUTCOME OF RADIOTHERAPY FOR ANUS CANCER INCLUDING LDR, PDR, AND HDR BRACHYTHERAPY. ADAPTED FROM PETRIC ET AL. 2022 (1). Reference EBRT Chemotherapy Boost [N] Brachytherapy Outcome [rate %] Patients [N] [Gy/Fx] IBT EBRT Dose Rate Dose [Gy] Y LC DFS OS

CFS

Papillon (40) N=369 Peiffert (50)

48/16

221

LDR

NS (15-20)

0,66

0,61

45-48/21-25

31%

101

LDR

22 (15-29)

80%

60%

pre-1989: 75% post-1989: 84%

N=118

Gerard (51)

48/16 39/13

100%

LDR

19 (14-28)

85%

84%

72%

N=95

Sandhu (52)

30-50/10-25

16%

LDR

24 (20-40)

78%

T1-2: 93% T3-4: 65%

71%

N=79

Weber (30) N=90 Chapet (47)

40/22

100%

LDR

19 (NS)

0,77

48/16 39/13

67%

218

LDR

20 (15-25)

83%

T1-2: 66% T3-4: 47%

T1-2: 77% T3-4: 63%

61%

N=252

Ortholan (16)

27-55/9-25

11%

LDR

20 (NS)

91%

89%

94%

85%

N=69 Bruna (53)

44-50/25

66%

PDR

18 (10-25)

90%

81%

90%

89%

N=71

36/12 45/25

Saarilahti (33) N=62 Tournier-R. (54)

100%

HDR

1-2 x 5-6 Gy

81%

77%

100%

30-50/7-25 17-50/10-30

44%

233

LDR/PDR

19 (10-37)

St I: 89% St II: 77%

St I: 82% St II: 67%

St I: 88% St II: 70%

N=286

St IIIA: 96% St IIIB: 77%

St IIIA: 54% St IIIB: 49%

St IIIA: 75% St IIIB: 56%

Oehler-J. (48)

45/25

72%

HDR

2 x 7 Gy

IBT: 90%

IBT: 76%

IBT: 66%

IBT: 85%

N=81

EBRT: 85% St I: 94% St II: 86% St III: 80% T1-2: 85% T3-4: 77% T1-2: 80% T3-4: 77%

EBRT: 73% St I: 70% St II: 57% St III: 27%

EBRT: 66% St I: 76% St II: 64% St III: 32% T1-2: 84% T3-4: 68% T1-2: 85% T3-4: 76%

EBRT: 82% St I: 76% St II: 58% St III: 25% T1-2: 72% T3-4: 51% T1-2: 81% T3-4: 78%

Widder (55)

46/23

74%

106

PDR/HDR

13 (5-26)

N=129

Hannoun-L. (25)

40-50/20-25

72%

LDR

17 (10-25)

N=162

Lestrade (32)

30-56/10-28

72%

209

LDR/PDR

18 (10-32)

T1-2: 70% T3-4: 68%

N=219

Cordoba (27)

38%

103

LDR

17 (10-30)

89%

86%

N=103 Kent (49)

45/25

100%

LDR

NS (15-20)

IBT: 91%

IBT: 75%

IBT: 97%

N=52

EBRT: 78%

EBRT: 68% T1-2: 84% T3-4: 64%

EBRT: 80% T1-2: 64% T3-4: 49%

Arcelli (37)

45/25

94%

102

PDR

20 (13-25)

T1-2: 84% T3-4: 79%

N=123

Doniec (35)

45/25

HDR

2 x 4-6 Gy

92%

T1-2 :88% T3-4 :67% IBT : 64% EBRT : 69% T1-2 : 80% T3-4 : 47%

74%

90%

N=50

Gryc (38)

50.4-59.4

89%

143

PDR

15.5 (8-35.8)

IBT : 76%

IBT :75%

IBT : 76%

N=190

/ 28-33

EBRT : 81% T1-2 : 80% T3-4 : 55%

EBRT : 72% T1-2 : 75% T3-4 : 58%

EBRT : 83% T1-2 : 94% T3-4 : 46%

Oblak (28)

45/25

89%

PDR

NS (15-30)

N=84

Falk (42)

43.2-50 / 24-26

75%

HDR

2-6 x 3-5 Gy

83%

72%

78%

75%

N=28

Kapoor (45)

40-45

100%

HDR

6-7 x 3 Gy

88%

N=16

/ 20-25

14. KEYMESSAGES

• Clinical examination and marking tumour with metal clips/markers and tattoo is of utmost importance to define CTV at the time of brachytherapy • Brachytherapy is limited to tumours extending to less than two thirds of the circumference and less than 1 cm thickness. • Anal canal brachytherapy is performed with interstitial needles preferably according to the rules of the Paris system, implanted in a single plane • The standard treatment scheme is a concomitant 45 Gy (1.8 Gy × 25) pelvic external beam radiotherapy and two courses of 5-fluorouracil and mitomycin, followed by a 15 Gy EQD2 brachytherapy boost. A 20 Gy EQD2 brachytherapy boost may be prescribed for poor responders after initial chemo-radiation therapy • PDR and HDR techniques seem to offer similar control and toxicity rates, but comparative trials are lacking • There is currently no consensus on the doses and dose fractionation for HDR brachytherapy, but should deliver a biological equivalent of 15 Gy in PDR/LDR techniques • Tumour regression can be observed up to 6 months after brachytherapy.

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