What if you can't get prior RT records??

[thesauce]

Saw a patient with a new diagnosis of high risk prostate cancer who had colectomy and adjuvant chemoradiation 30 years ago for an adenocarcinoma of the rectosigmoid flexure. According to the institution that treated him, all of his records were destroyed.

He wants RT for his prostate cancer. How would you proceed?

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[thecarbonionangle]

Not an unusual situation i run into as I do a lot of reirradiation. I basically assume the worst. Say prescription was likely 50-55 reasonable to assume a 5-10 percent hot spot, then i “forgive” half, and take a look at what I can do with that assumption. Remember there is no OS benefit to dose escalation. You can drop the dose a bit if needed.

 

[Palex80]

Agree with @thecarbonionangle.
I also perform some more workup in these patients. In your case, I'd order a cystoscopy and a rectoscopy, just to get an impression of what the mucosa looks like.

 

[thesauce]

Not an unusual situation i run into as I do a lot of reirradiation. I basically assume the worst. Say prescription was likely 50-55 reasonable to assume a 5-10 percent hot spot, then i “forgive” half, and take a look at what I can do with that assumption. Remember there is no OS benefit to dose escalation. You can drop the dose a bit if needed.

I guess this biggest concern here is that I have no clue what a colon cancer radiation treatment field or dose would be like since it predates my training...would the prostate have gotten RT?

 

[Palex80]

I guess this biggest concern here is that I have no clue what a colon cancer radiation treatment field or dose would be like since it predates my training...would the prostate have gotten RT?

(Really) old textbooks in a department library are useful for exactly this reason. My boss likes to keep some of them around.

 

[thesauce]

(Really) old textbooks in a department library are useful for exactly this reason. My boss likes to keep some of them around.

A textbook?? So funny I didn't even think of that

 

[Bequerel]

Wouldn’t that just be an old school rectal field which would definitely treated the rectum behind prostate to 50? I’d try to avoid RT if possible with no prior records. What’s MRI look like? Any ECE?

 

[RadRadRad]

I’d assume the prostate was in prior fields
Could have been just AP pa back then. Even if 3-4 field with laterals a good portion of prostate would be included

He had apr? No rectum now? Would be good case for brachy / brachy boost if you had to treat but I don’t know how to do that without trus

 

[elementaryschooleconomics]

(Really) old textbooks in a department library are useful for exactly this reason. My boss likes to keep some of them around.

Same! I have a few old textbooks that have definitely "filled in the blanks" for me, from time to time.

 

[ramsesthenice]

Saw a patient with a new diagnosis of high risk prostate cancer who had colectomy and adjuvant chemoradiation 30 years ago for an adenocarcinoma of the rectosigmoid flexure. According to the institution that treated him, all of his records were destroyed.

He wants RT for his prostate cancer. How would you proceed?

Why high risk? If you omit nodes and just treat prostate you should be fine. I’ve done HDR + ADT a couple times for this with no problems.

 

[TheWallnerus]

If focusing on the "colectomy" and "rectosigmoid" aspects of the case presentation, I believe we have a patient that had adjuvant treatment for a *colon* cancer back when there was compulsion/excitement (whatever) about adjuvant chemoRT for colon cancer. I have done a lot of adjuvant chemoradiation for colon cancer. The prostate would never have been in the field unless you were a bad rad onc. Were there bad rad oncs 30 years ago? Yes. Was the patient treated by a bad rad onc? Who knows. I would have GI look at the peri-prostatic rectum. If it looks perfectly normal I think you can assume the prostate and at least nearby surrounding tissue has been unirradiated. That said, would not do ENI on this fellow.

 

[Ray D. Ayshun]

If there's concern about overlap, is the only reason surgery is out patient preference? We know that there are commonly patient who are high risk that shouldn't be operated on, but the truth is, cancer outcomes are no different. Hence, it's generally a tie, with the win going to patient preference. This sounds like a prostatectomy win, unless there's some other issue.

 

[RadRadRad]

If focusing on the "colectomy" and "rectosigmoid" aspects of the case presentation, I believe we have a patient that had adjuvant treatment for a *colon* cancer back when there was compulsion/excitement (whatever) about adjuvant chemoRT for colon cancer. I have done a lot of adjuvant chemoradiation for colon cancer. The prostate would never have been in the field unless you were a bad rad onc. Were there bad rad oncs 30 years ago? Yes. Was the patient treated by a bad rad onc? Who knows. I would have GI look at the peri-prostatic rectum. If it looks perfectly normal I think you can assume the prostate and at least nearby surrounding tissue has been unirradiated. That said, would not do ENI on this fellow.

Guess we need clarification on location and type of surgery
If I have a true rectosigmoid cancer requiring radiation I’m treating pelvis but maybe this was no rectosigmoid maybe just sigmoid ?

 

[thesauce]

Wouldn’t that just be an old school rectal field which would definitely treated the rectum behind prostate to 50? I’d try to avoid RT if possible with no prior records. What’s MRI look like? Any ECE?

No this was truly colon which I guess they treated with chemoRT in the 1990s. He does not have an APR.

No ECE on MRI

 

[Palex80]

No this was truly colon which I guess they treated with chemoRT in the 1990s. He does not have an APR.

No ECE on MRI

I would seriously have a coloscopy & cystoscopy done. It's possible that you will see post-radiation changes in parts of the colon and the bladder that may allow you to assume where does was delivered to back then.

 

[TheWallnerus]

Wouldn’t that just be an old school rectal field which would definitely treated the rectum behind prostate to 50? I

Not if it was old-school colon RT fields (usually was AP/PA to an abdominal quadrant, more or less)

I’d assume the prostate was in prior fields

I wouldn't if the surgeon said "colectomy"

I would seriously have a coloscopy & cystoscopy done.

Yes (and he should have been having colonoscopies every several years since RT, theoretically)

 

[evilbooyaa]

Always learn something new from SDN... RT for colon cancer was a thing as recently as in the '90s?

 

[medgator]

Always learn something new from SDN... RT for colon cancer was a thing as recently as in the '90s?

Yep. Ovarian in 80s too i think?

 

[evilbooyaa]

Yep. Ovarian in 80s too i think?

I learned the WAR trials that lead to loss of ovarian... but colon cancer was basically always a 'lol can't treat that in any signifiant manner'

 

[RadRadRad]

I learned the WAR trials that lead to loss of ovarian... but colon cancer was basically always a 'lol can't treat that in any signifiant manner'

Pretty sure there was an intergroup trial of chemo vs chemorads for resected colon cancer. Got published but didn't meet accrual goal

 

[bigman1]

I learned the WAR trials that lead to loss of ovarian... but colon cancer was basically always a 'lol can't treat that in any signifiant manner'

There's actually a number of trials going on right now that will bring RT back into primary ovarian

 

[Lamount]

Always learn something new from SDN... RT for colon cancer was a thing as recently as in the '90s?

Does postoperative irradiation play a role in the adjuvant therapy of stage T4 colon cancer? - PubMed

 

[evilbooyaa]

There's actually a number of trials going on right now that will bring RT back into primary ovarian

Links?