title: Dose-painted intensity-modulated radiation therapy for anal cancer: a multi-institutional report of acute toxicity and response to therapy.
abstract: OBJECTIVE
  Chemoradiation for anal cancer yields effective tumor control, but is associated with significant acute toxicity. We report our multi-institutional experience using dose-painted IMRT (DP-IMRT).
  
  
  METHODS
  Between August 2005 and May 2009, 43 patients were treated with DP-IMRT and concurrent chemotherapy for biopsy-proven, squamous cell carcinoma of the anal canal at two academic medical centers. DP-IMRT was prescribed as follows: T2N0: 42 Gy, 1.5 Gy/fraction (fx) to elective nodal planning target volume (PTV) and 50.4 Gy, 1.8 Gy/fx to anal tumor PTV; T3-4N0-3: 45 Gy, 1.5 Gy/fx to elective nodal PTV, and 54 Gy, 1.8 Gy/fx to the anal tumor and metastatic nodal PTV >3 cm with 50.4 Gy, 1.68 Gy/fx to nodal PTVs ≤ 3 cm in size. Acute and late toxicity was reported by the treating physician. Actuarial analysis was performed using the Kaplan-Meier method.
  
  
  RESULTS
  Median age was 58 years; 67% female; 16% Stage I, 37% II; 42% III; 5% IV. Fourteen patients were immunocompromised: 21% HIV-positive and 12% on chronic immunosuppression. Median follow-up was 24 months (range, 0.6-43.5 months). Sixty percent completed chemoradiation without treatment interruption; median duration of treatment interruption was 2 days (range, 2-24 days). Acute Grade 3+ toxicity included: hematologic 51%, dermatologic 10%, gastrointestinal 7%, and genitourinary 7%. Two-year local control, overall survival, colostomy-free survival, and metastasis-free survival were 95%, 94%, 90%, and 92%, respectively.
  
  
  CONCLUSIONS
  Dose-painted IMRT appears effective and well-tolerated as part of a chemoradiation therapy regimen for the treatment of anal canal cancer.
authors.affiliation: Department of Radiation Oncology, Boston Medical Center, Boston, MA 02118, USA. lisa.kachnic@bmc.org
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Kachnic
authors.forename: Henry K
authors.initials: HK
authors.lastname: Tsai
authors.forename: John J
authors.initials: JJ
authors.lastname: Coen
authors.forename: Lawrence S
authors.initials: LS
authors.lastname: Blaszkowsky
authors.forename: Kevan
authors.initials: K
authors.lastname: Hartshorn
authors.forename: Eunice L
authors.initials: EL
authors.lastname: Kwak
authors.forename: John D
authors.initials: JD
authors.lastname: Willins
authors.forename: David P
authors.initials: DP
authors.lastname: Ryan
authors.forename: Theodore S
authors.initials: TS
authors.lastname: Hong
mesh_terms: D000206:Actuarial Analysis / Q000379:methods; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001005:Anus Neoplasms / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy*; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy* / Q000556:secondary; D059248:Chemoradiotherapy / Q000009:adverse effects / Q000379:methods; D002945:Cisplatin / Q000008:administration & dosage; D018572:Disease-Free Survival; D057915:Drug Substitution; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D041981:Gastrointestinal Tract / Q000528:radiation effects; D006402:Hematologic Diseases / Q000209:etiology; D006801:Humans; D015182:Lymphatic Irradiation / Q000379:methods; D008297:Male; D008875:Middle Aged; D016685:Mitomycin / Q000008:administration & dosage; D011855:Radiodermatitis / Q000209:etiology; D011859:Radiography; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D016896:Treatment Outcome; D047368:Tumor Burden / Q000528:radiation effects; D014566:Urogenital System / Q000528:radiation effects
chemical_list: D016685:Mitomycin; D002945:Cisplatin; D005472:Fluorouracil