Anal Canal Cancer

18
Joey G. Bazan, Albert C. Koong, and Daniel T. Chang

General Principles of Target Delineation

• Physical examination is an important part of the staging and planning process as well
as adequate imaging studies. Standard studies include CT of the pelvis to assess the
primary tumor and the status of regional lymph nodes. These tumors can be well
visualized on PET, so a PET/CT scan is becoming a standard part of staging and
planning to help delineate the extent of gross disease. However, areas of low uptake
on PET should not supercede physical exam findings or abnormalities seen on CT.
• CT simulation with IV contrast should be performed to delineate the pelvic blood
vessels and gross tumor volume. If PET/CT is available, a PET/CT fusion should
be obtained to aid in target volume delineation. A radiopaque marker should be
placed on the anus.
• The patient can be simulated in the supine position in a body mold or other
immobilization device to ensure setup reproducibility. Prone position with the
use of a belly board can be used to allow for anterior displacement of the bowel,
but setup reproducibility is more variable and using bolus or additional electron
fields to supplement dose to the inguinal regions would not be possible.
• Bladder filling/emptying should be considered. A full bladder may keep bowel
from migrating into the pelvis. An empty bladder may be more reproducible.
• Lymph nodes in the inguinal region that are suspicious but borderline should be
biopsied.
• Suggested target volumes of the various CTVs are described in Table 18.1 [1, 2].
Of note, there are multiple techniques and methods of dose prescription for anal
cancer, and the exact dose fractionation will vary based on which technique is
used. The current recommendations are based on the treatment plan used in RTOG
98-11 [3]. RTOG 0529 has recommendations on contouring for IMRT [4].

J.G. Bazan, M.D. • A.C. Koong, M.D., Ph.D. • D.T. Chang ()
Department of Radiation Oncology, Stanford University,
Stanford, CA, USA
e-mail: dtchang@stanford.edu

N.Y. Lee, J.J. Lu (eds.), Target Volume Delineation and Field Setup, 169
DOI 10.1007/978-3-642-28860-9_18, © Springer-Verlag Berlin Heidelberg 2013
170 J.G. Bazan et al.

Table 18.1 Suggested target volumes at the gross disease region

Target volumes Definition and description
GTV (gross tumor volume) Primary: all gross disease on physical examination and
imaging
Regional nodes: all nodes ³1.5 cm, PET-positive, or
biopsy-proven; include any lymph node in doubt as GTV in
the absence of a biopsy
CTV (gross disease) Should cover the GTV with 1.5–2.5-cm margin expansion but
exclude uninvolved bone, muscle, or air
CTV (high risk) Should cover the entire mesorectum, the right and left internal
iliac lymph nodes inferior to the inferior-most level of the
sacroiliac joint, and the inguinal or external iliac lymphatics if
the inguinal nodes are involved
To cover the iliac lymphatics, a 0.7-cm margin around the
iliac vessels should be drawn (excluding muscle and bone). To
cover the external iliac vessels, an additional 1-cm margin
anterolaterally is needed. Any adjacent small lymph nodes
should be included
Anteriorly, a 1–1.5-cm margin should be added into bladder to
account for changes in bladder and rectal filling changes [5]
A 1.8-cm wide volume between the external and internal iliac
vessels is needed to cover the obturator nodes
CTV (low risk) Should include the uninvolved inguinal, external iliac, and
internal iliac nodes superior to the inferior-most level of the
sacroiliac joint
To cover the lymph nodes, a 0.7-cm margin around the iliac
vessels should be drawn (excluding muscle and bone). To
cover the external iliac vessels, an additional 1-cm margin
anterolaterally is needed. Any nearby small lymph nodes
should be included
Anteriorly, a 1–1.5-cm margin should be added into bladder to
account for changes in bladder and rectal filling changes [5]
A 1.8-cm wide volume between the external and internal iliac
vessels is needed to cover the obturator nodes
PTV CTV should be expanded by 0.5–1 cm, depending on the
physician’s comfort level with setup accuracy, frequency of
imaging, and the use of IGRT

• Suggested dose to PTV (high risk) is 1.8 Gy/fraction to 45 Gy.

• Suggested dose to PTV (low risk) is 1.8 Gy/fraction to 36 Gy or 1.6 Gy/fraction
to 40 Gy (if using simultaneous integrated boost with IMRT).
• Suggested PTV (gross disease) dose is 1.8 Gy/fraction to 50.4 Gy for T2N0
tumor and 54–59.4 Gy for T2N+ or T3–4 N0–1 disease (sequential cone down
after 45 Gy).
• Suggested dose for T1N0 tumors is 45–50.4 Gy at 1.8 Gy/fraction.
• Additional dose scheduling regimens can be used with IMRT using simultaneous
integrated boost technique. However, caution should be used when using >2 Gy
per fraction to the primary tumor. The authors recommend 1.8 Gy per fraction as
the maximum daily dose to the primary tumor (Figs. 18.1, 18.2, and 18.3).
18 Anal Canal Cancer 171

Fig. 18.1 An example of how PET can help delineate GTV. The GTV (red) is seen on representative
axial, sagittal, and coronal images, respectively, on both the treatment planning CT and PET in the
upper panels. Additional representative axial slices are shown below in the lower panels
172 J.G. Bazan et al.

Bottom of
SI joint

Coverage of
external iliac
nodes

>1.5 cm margin
around primary
tumor (except at
uninvolved
muscle/bone)

Fig. 18.2 (a) A patient with T2N0 anal canal cancer. This patient was simulated supine using
PET/CT simulation with a 2.5-mm thickness on each slice. CTV is shown. Note that these are
representative slices and not all slices are included. CTV (low risk – cyan), CTV (high risk –
orange), CTV (gross disease – green), and GTV (red, shaded) are shown. (b) Enhanced view of
lower pelvis showing CTV (low risk – blue), CTV (high risk – orange), CTV (gross disease –
green), and GTV (red, shaded)
18 Anal Canal Cancer 173

CTV (low risk)

blue

CTV (gross disease)

green

CTV (high risk)

orange

Fig. 18.2 (continued)

174 J.G. Bazan et al.

Coverage of
external iliac
nodes

Bottom of
SI joint

Involved groin
nodes

Involved groin
regions in CTV
(high risk)

>1.5 cm margin
around primary
tumor and Iymph
nodes (except at
uninvolved
muscle/bone)

Fig. 18.3 (a) A patient with T3N3 anal canal cancer with bilateral inguinal lymph node involvement.
This patient was simulated supine using PET/CT simulation with a 2.5-mm thickness on each
slice. CTV (low risk – cyan), CTV (high risk – orange), CTV (gross disease – green), and GTV
(red, shaded) are shown. Note that these are representative slices and not all slices are included. (b)
Enhanced view of lower pelvis showing CTV (high risk – orange), CTV (gross disease – green),
and GTV (red, shaded)
18 Anal Canal Cancer 175

CTV (gross disease)

green

CTV (high risk)

orange

Fig. 18.3 (continued)

References
1. Myerson RJ, Garofalo MC, El Naqa I et al (2009) Elective clinical target volumes for conformal
therapy in anorectal cancer: a radiation therapy oncology group consensus panel contouring
atlas. Int J Radiat Oncol Biol Phys 74:824–830
2. Taylor A, Rockall AG, Reznek RH et al (2005) Mapping pelvic lymph nodes: guidelines for
delineation in intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 63:1604–1612
3. Ajani JA, Winter KA, Gunderson LL et al (2008) Fluorouracil, mitomycin, and radiotherapy vs.
fluorouracil, cisplatin, and radiotherapy for carcinoma of the anal canal: a randomized con-
trolled trial. JAMA 299:1914–1921
4. Kachnic L, Myerson R, Goodyear M, Willians J, Esthappan J (2006) RTOG 0529: a phase II
evaluation of dose-painted IMRT in combination with 5-Fluorouracil and mitomycin-C for
reduction of acute morbidity in carcinoma of the anal canal. http://www.rtog.org/ClinicalTrials/
ProtocolTable/StudyDetails.aspx?study=0529. Accessed on January 5, 2012.
5. Daly ME, Murphy J, Mok E, Christman-Skieller C, Koong AC, Chang DT (2011) Rectal and
bladder deformation and displacement during pre-operative radiotherapy for rectal cancer: are
current margin guidelines adequate for conformal therapy? Pract Radiat Oncol 1:10