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Development of a consensus-based delineation guideline for locally recurrent rectal cancer

  • Author Footnotes
    1 Both authors contributed equally.
    Floor Piqeur
    Footnotes
    1 Both authors contributed equally.
    Affiliations
    Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands

    Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands

    Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands
    Search for articles by this author
  • Author Footnotes
    1 Both authors contributed equally.
    Britt J.P. Hupkens
    Footnotes
    1 Both authors contributed equally.
    Affiliations
    Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands

    Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Doctor Tanslaan 12, 6229ET Maastricht, the Netherlands
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  • Stefi Nordkamp
    Affiliations
    Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands
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  • Marnix G. Witte
    Affiliations
    Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
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  • Philip Meijnen
    Affiliations
    Department of Radiation Oncology, Amsterdam University Medical Centre, De Boelelaan 1118, 1081HZ Amsterdam, the Netherlands
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  • Heleen M. Ceha
    Affiliations
    Department of Radiation Oncology, Haaglanden Medical Centre, Burg. Banninglaan 1, 2262AK Leidschendam, the Netherlands
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  • Maaike Berbee
    Affiliations
    Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Doctor Tanslaan 12, 6229ET Maastricht, the Netherlands
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  • Margriet Dieters
    Affiliations
    Department of Radiation Oncology, University Medical Centre Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
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  • Sofia Heyman
    Affiliations
    Department of Oncology, Institute of Clinical Sciencs, Sahlgrenska Academy at University of Gothenburg, Bla straket 5, 412 45 Götenborg, Sweden
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  • Alexander Valdman
    Affiliations
    Department of Radiation Oncology, Karolinska University Hospital, Anna Steckséns gata 41, 171 64 Stockholm, Sweden
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  • Martin P. Nilsson
    Affiliations
    Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23, 221 85 Lund, Sweden
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  • Joost Nederend
    Affiliations
    Department of Radiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
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  • Harm J.T. Rutten
    Affiliations
    Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands

    GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40, 6229ER Maastricht, the Netherlands
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  • Jacobus W.A. Burger
    Affiliations
    Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands
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  • Corrie A.M. Marijnen
    Affiliations
    Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands

    Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands
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  • Heike M.U. Peulen
    Correspondence
    Corresponding author at: Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands.
    Affiliations
    Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands
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  • Author Footnotes
    1 Both authors contributed equally.
Published:November 18, 2022DOI:https://doi.org/10.1016/j.radonc.2022.11.008

      Highlights

      • Delineation in LRRC is complex due to heterogeneous disease and absence of guidelines.
      • Inter-observer variation in LRRC is large.
      • Multidisciplinary target volume definition is essential.
      • QA data from PelvEx II trial will provide further insight in target volumes.

      Abstract

      Background and purpose

      Neoadjuvant chemoradiotherapy (nCRT) is used in locally recurrent rectal cancer (LRRC) to increase chances of a radical surgical resection. Delineation in LRRC is hampered by complex disease presentation and limited clinical exposure. Within the PelvEx II trial, evaluating the benefit of chemotherapy preceding nCRT for LRRC, a delineation guideline was developed by an expert LRRC team.

      Materials and methods

      Eight radiation oncologists, from Dutch and Swedish expert centres, participated in two meetings, delineating GTV and CTV in six cases. Regions at-risk for re-recurrence or irradical resection were identified by eleven expert surgeons and one expert radiologist. Target volumes were evaluated multidisciplinary. Inter-observer variation was analysed.

      Results

      Inter-observer variation in delineation of LRRC appeared large. Multidisciplinary evaluation per case is beneficial in determining target volumes. The following consensus regarding target volumes was reached. GTV should encompass all tumour, including extension into OAR if applicable. If the tumour is in fibrosis, GTV should encompass the entire fibrotic area. Only if tumour can clearly be distinguished from fibrosis, GTV may be reduced, as long as the entire fibrotic area is covered by the CTV. CTV is GTV with a 1 cm margin and should encompass all at-risk regions for irradical resection or re-recurrence. CTV should not be adjusted towards other organs. Multifocal recurrences should be encompassed in one CTV. Elective nodal delineation is only advised in radiotherapy-naïve patients.

      Conclusion

      This study provides a first consensus-based delineation guideline for LRRC. Analyses of re-recurrences is needed to understand disease behaviour and to optimize delineation guidelines accordingly.

      Keywords

      Abbreviations:

      LRRC (Locally recurrent rectal cancer), GTV (Gross tumour volume), CTV (Clinical target volume), PTV (Planning target volume), nCRT (Neoadjuvant chemoradiotherapy), OAR (Organs at risk), R0 (Radical resection), OS (Overall survival), RCT (Randomized controlled trial), DSC (Dice similarity coefficient), HD (Hausdorff distance), QA (Quality Assurance)
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