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However, we do not recommend routine clinical use of focal dose escalation using FDG-PET/CT-guided IMRT.
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Based on the results of this planning study, we will start a clinical phase I/II study of focal dose escalation using PET-guided IMRT for patients with postoperative local recurrent rectal cancer in our institution.
Unilateral focal disease has been treated using DCE imaging to contour the DIL with the intent of focal dose escalation.
To evaluate the safety of focal dose escalation to regions with standardized uptake value (SUV) >2.0 using intensity-modulated radiation therapy (IMRT) by comparison of radiotherapy plans using dose-volume histograms (DVHs) and normal tissue complication probability (NTCP) for postoperative local recurrent rectal cancer First, we performed conventional radiotherapy with 40 Gy/20 fr.
Preliminary results indicate feasibility of focal dose escalation to the FDG-PET positive region, with acceptable toxicity.
However, although NTCP which reflects account all the DVH data was not increased, Dmax of small bowel PRV in the summed plan using focal dose escalation was significantly higher than that in other summed plans.
In comparison, the use of focal LDR brachytherapy is still in its early stages.
Single focal dose (SFD) of external irradiation was 2 Gy.
Since it is known that the small bowel is a "serial organ" and that the dose at which probability of obstruction or perforation is 50% within 5 years after treatment (TD50/5) of the small bowel is 55 Gy [ 32], although NTCP shows that focal dose escalation is acceptable, dose escalation by only 6 Gy from 60 Gy even using PET-guided IMRT is relatively risky.
There exist ample opportunities for multimodality fusion of mpMRI as well as intra-operative MRI for focal dose escalation.
In the present study, since V30, V40, V60, Dmean and NTCP of small bowel PRV were not increased and V50 of small bowel PRV could be reduced due to the differences between GTV2 and BTV, focal dose escalation by 6 Gy to regions with SUV above 2.0 using IMRT with dose-painting boost for postoperative local recurrent rectal cancer is considered to be safe.
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