How to Reduce Radiation Induced Side Effects from the Treatment of

Rectal Cancer

Vanessa Hockenhull
July 23, 2014

There are many side effects associated with the radiation treatment of rectal cancer.
These side effects, rather short or long term, are an added confliction to the patients quality of
life. Having to go through treatments and also deal with the presenting symptoms of the disease
is enough for what the patient should have to go tolerate. It should be a goal throughout all
departments to take all measures to ensure the most amount of reduction from radiation therapy
induced side effects. Research on this topic has currently been conducted. Collecting data from
various angles associated with the treatment such as imaging, patient positioning, and treatment
techniques helps to pinpoint the best radiation treatment for quality of patient care. There is still
a bit of a gray area about the use of CT or MRI for imaging, supine versus prone with belly
board, IMRT or three field conformal for treatment technique. The hypothesis of this paper has
been assessed from the research proving that precise imaging, reproducibility, and the sparing of
normal tissue will have a huge impact on the quality of patient care.
The belief of this paper is that the use of magnetic resonance imaging (MRI), supine
positioning, and intensity modulated radiation therapy (IMRT) treatment technique will spare the
patient the harsh effects of radiation therapy. Keeping healthy tissue from being treated is
believed to be feasible with these techniques. MRI has been studied to provide the more
accurate diameter of the tumor. This data would allow for smaller treatment margins to plan off
of. Treating patients in a supine position allows for a more reproducible target compared to
prone with a belly board. This would benefit to the elimination of over or under dosing
treatment volume and critical structures. IMRT provides the ability to give treatment to very
small regions and spread out different doses within parts of one treatment field. Critical
structures could be avoided much easier. This has been proven throughout the treatment of many
different malignancies.

According to Washington, the radiation induced side effects of rectal cancer range from
acute to chronic. Acute side effects include diarrhea, abdominal cramping and bloating, bloody
mucus or discharge, or dysuria. Chronic side effects include persistent diarrhea, proctitis, urinary
incontinence, bladder atrophy, damage to small bowel leading to enteritis, adhesions, or
obstruction. The study conducted by Birgisson et al took data from three groups of articles.
Each article had documentation of late side effects of radiation for rectal cancer. The effects
found were gastrointestinal disorders, neurological problems, anal, rectal, urinary and sexual
dysfunction, pelvic or hip fractures, thromboembolic diseases and secondary cancers. The article
also stressed the importance of careful patient selection for radiation therapy for rectal cancer.
Although this is true, the most important factor is figuring out precise techniques for
administering radiation. The article did not include which groups were prone or supine, IMRT or
three field conformal. It would have been useful to know more details about treatment so
planning of this proposal could rule out failed techniques. Nevertheless, these side effects are
obviously substandard and planning needs to involve ways to avoid them.
The article written by Oneill et al addresses the benefits of MRI. A sample size of ten
patients between the ages of sixty-one and sixty-three was used. The patients first underwent a
CT scan in a prone and supine position followed by an MRI with the same positions two weeks
later. CT overestimated tumor volumes. The mean difference in tumor volume was eighteen
centimeters greater on CT compared to MRI. Although the CT is good at giving anatomical
tumor information, low contrast resolution is limited. Oneill et all discusses how the gross
tumor volume on CT can look like a huge gray mass while MRI will show the difference in
rectal mucosa, muscularis, and peritoneum. This was a great study to prove the clarity of MRI.
A couple concerns are of some missing information such as patient size and laser localization.

Since the MRI has smaller width, it would be good to know the width of the patients hips. There
is also not a good explanation on how the patients were lined up in the same position as CT for
the MRI without lasers.
Drzymala et al conducted a study on rectal cancer patients imaged with CT in the prone
or supine position. MRI was used to assess tumor size. Patients were asked to drink 750 ml of
water in ten to fifteen minute intervals without emptying their bladder for forty to sixty minutes.
When assessing the planning target volume (PTV), bowel and bladder volumes, there was no
statistically significant difference between prone and supine. A belly board was not used in this
study because of an article by Allal et al who found it was not reproducible in the anterior and
posterior direction. This article favors the proposal of treating rectal cancer in the supine
position and finding reproducibility is the main focus. Since the tumor margins are the same in
both positions, choosing the more reproducible one would allow for more advanced treatment
techniques to be adopted.
Another study used the belly board and concluded that it spared more bowel and bladder
compared to just prone and supine positioning. Nijkamp et al mentioned how the full bladder
can result in unstability, but it is clinically not feasible to use an empty bladder. A full bladder
helps for critical structures such as small bowel, uterus or prostate to be moved away from the
rectum. Patients went through four MRI scans. Supine, prone, and two bellyboards resulted in
the four different positionings for each patient. The authors agreed with previous research that
the belly board could cause the positioning of the patient to vary from day to day. The
suggestion was to increase the PTV to make up for this. This is a good take on treatment but
when focusing more closely on decreasing side effects, the belly board is not efficient enough for
smaller field sizes.

The study about IMRT versus conformal, used prone positioning with a belly board and
supine positioning. Sixty-six percent of the belly board patients were treated conformal and
eighty-eight of the supine patients were treated IMRT. IMRT had a clinical target volume (CTV)
of two centimeters and a planning target volume (PTV) between one half and one centimeters.
The article does not state the field size of the conformal treatment. Gastrointestinal (GI) grade 2
toxicities included nausea, vomiting, diarrhea, enteritis, proctitis, dehydration, and any other GI
toxicity. Non-GI grade 2 toxicities included hematologic counts, urinary, and skin. Thirty-two
percent of IMRT patients experienced GI toxicities and sixty-two percent of conformal patients
experienced them. The conformal field width should have been mentioned, but it can be
assumed that it was bigger than the IMRT margins. It would have also been nice to include
different data comparing the prone and supine positioning. This study is a good lead to further
studies of IMRT for rectal cancer.
A study involving all of the aspects in this paper would be beneficial. For the study, a
group of thirty patients should be used. Age range, stage, and grade should be similar. Any far
metastasis should not be a part of the setup. For the age range, sixties would be beneficial. All
patients should have full bladders. An even number of males and females, normal weight and
overweight should be used. Patients from hospitals around America can be used. Because the
James Cancer Hospital uses belly boards, there needs to be a group of patients with a belly board
set up and a group supine with a vacbag. Patients should be divided equally into both of these
groups. Fifteen patients including seven overweight and eight normal weight should be
positioned prone in a belly board. The same numbers should be supine in a vacbag. Three of the
overweight patients and four of the normal weight patients on belly boards should be scanned
MRI. Four of the overweight patients and three of the normal weight patients on belly boards

should be scanned CT. The same numbers go for the supine group of patients. The reason for
using overweight patients is too observe the accuracy of reproducibility with extra body fat. Half
of the MRI scanned patients should get an IMRT plan and the other half should get a three field
conformal plan. The same goes for CT. After treatment, patients should come in for a month
and yearly check-ups to review if they are experiencing any side effects or have recurrence.
Table 1 describes the study.
The results from the study are expected to agree with the hypothesis of this paper. It is
expected that the four patients who had supine positions, were imaged with MRI and were given
IMRT plans would have the least side effects. The two overweight patients should still have less
side effects than the other groups. Even though this may seem like a small number, the data is
still useful because the overall comparison of MRI versus CT and IMRT versus conformal can be
assessed. MRI and IMRT are expected to have the more benefiting overall results.
All patients should have some sort of acute side effects even if it is at least a skin
reaction. Through previous research conformal plans are likely to give patients the most of all
possible side effects. IMRT plans are predicted to be more efficient at avoiding the acetabulum,
femoral head, most of bowel and bladder. When used with MRI this should be especially true.
Long term pelvic or hip fractures, gastrointestinal and urinary disorders are more expected with a
greater conformal field. If the prediction were to be false, the expectation is that the MRI would
flaw because of the ability to setup the same on the treatment machine. The other flaw to prove
the hypothesis is that the patients to meet all criteria may be hard to find. Some may need to be
omitted and then the results may be skewed slightly. Predicted results are in table 2.

Table 1

*The overweight and normal patients are divided equally between prone belly board and supine.
*Ex: Out of the 8 supine IMRT patients, 4 were CT and 4 were MRI. Two of the CT and MRI
were overweight and 2 were normal weight.

MRI

CT

7 (patients) belly

belly board

IMRT

3 field

7 belly board

belly board

board
8 supine

7 supine

8 supine

7 supine

7 overweight

8 overweight

7 overweight

8 overweight

8 normal weight

7 normal weight

8 normal weight

7 normal weight

Table 2

MRI/IMRT

MRI/Conf

CT/IMRT

CT/Conf

Belly board

Bellyboard

Belly board

Belly board

Less side effects

Greater side effects

Medium side effects

Maximum side effects

Supine

Supine

Supine

Supine

Minimal side effects

Greater side effetcs

Less side effects

Greater side efects

*Order from least possible amount of side effects to most side effects is ranged: Minimal, Less,
Medium, Greater, Maximum.

References

1. Washington, C., Leaver, D., Principles and Practice of Radiation Therapy, 3rd
Edition, 2010, Mosby, St. Louis, MO.
2.

3. Birgisson, Helgi et al., Late adverse effects of radiation therapy for rectal cancer a
systematic overview. Acta Oncologica, 2007; 46: 504 516.
4. Oneill, B et al., MR vs CT imaging: low rectal cancer tumor delineation for threedimensional conformal radiotherapy. The British Journal of Radiology, 2009; 82: 509
513.
5. Drzymala, M et al., The effect of treatment position, prone or supine, on dose-volume
histograms for pelvic radiotherapy in patients with rectal cancer. The British Journal
of Radiology, 2009; 82: 321 -327.
6. Nijkamp, Jasper et al., Bowel exposure in rectal cancer IMRT using prone, supine, or
a belly board. Elsevier Radiotherapy and Oncology, 2012; 102: 22 29.
7. Samuelian, Jason., Reduced acute bowel toxicity in patients treated with intensity-

modulated radiotherapy for rectal cancer. Int. J.Radiation Oncology Biol. Phys., 2012;
82: 1981 1987.