Table Of ContentMEDICAL RADIOLOGY
Diagnostic Imaging and Radiation Oncology
Editorial Board
L. W. Brady, Philadelphia· M. W. Donner, Baltimore
H.-P. Heilmann, Hamburg· F. Heuck, Stuttgart
Gastrointestinal
Cancer
Radiation Therapy
Contributors
Y.l.Belcastro . P.P.Carbone . B.J.Cummings . L.J.A.DiDio
RRDobelbower, lr. . D.E.Dosoretz . RA.DuBrow . RJ.Fadell
F.B.Gelder· P.l.Goldblatt . M.Haghbin . E.J.Hinson . J.M.Howard
M.l.Katin· K.Kim . L.Komarnicky . J.Korinek . B.Levin
J. H. Meerwaldt . W. M. Mendenhall . R R Million . M. Mohiuddin
Y. B. Pinto· G. Ramirez· B. Sischy . St. M. Wagner
Edited by
Ralph R. Dobelbower, Jr.
Foreword by
Luther W. Brady and Hans-Peter Heilmann
With 76 Figures
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo Hong Kong
RALPH R.DoBELBOWER, JR., M.D., Ph.D., F.A.C.R.
Professor and Chainnan
Department of Radiation Therapy
Professor of Neurological Surgery
(Radiation Therapy)
Medical College of Ohio
3000 Arlington Avenue
C.S.10008
Toledo, OH 43699
USA
MEDICAL RADIOLOGY· Diagnostic Imaging and Radiation Oncology
Continuation of
Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
ISBN-13: 978-3-642-83659-6 8-ISBN-13: 978-3-642-83657-2
001: 10.1007/978-3-642-83657-2
Library of Congress Cataloging-in-Publication Data. Gastrointestinal cancer: radiation therapy I contributors, V.J. Bel
castro ... let al.l ; edited by Ralph R. Dobelbower, Jr. ; foreword by Luther W. Brady and Hans-Peter Heilmann. p. cm. -
(Medical radiology) Includes bibliographical references.
1. Digestive organs -Cancer. 2. Digestive organs -Cancer - Radiotherapy. I. Belcastro, V.l. (Vincent J.) II. Dobelbower,
Ralph R. III. Series.
[DNLM: 1. Digestive System Neoplasms - radiotherapy. WI 149 G2568l RC280.D5G374 1990 616.99'4330642
-dc20
DNLM/DLC 89-21870 CIP
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, spe
cifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms
or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the
provisions of the German Copyright Law of September 9,1965, in its version of June 24, 1985, and a copyright fee must
always be paid. Violations fall under the prosecution act of the German Copyright Law.
© Springer-Verlag Berlin Heidelberg 1990
Softcover reprint of the hardcover 1st edition 1990
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific state
ment, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
Product Liability: The publishers can give no guarantee for information about radiation or drug dosage and application
thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other
pharmaceutical literature.
This book is dedicated to my wife, Mary Louise Dobelbower,
and our seven children, without whose patience, love, dedication,
and sacrifice this work would not have come to fruition.
RALPH R. DOBELBOWER, JR., 1989
"The answers to my questions are not found in any book"
RALPH R. DOBELBOWER, SR.,
in his ninth decade 1981
List of Contributors
VINCENT J. BELCASTRO, M. D. DANIEL E. DOSORETZ, M. D.
Belcastro and Carrasquillo Radiation Therapy Regional Center
Surgical Associates Radiation Therapy Associates
Cape Coral Hospital 3680 Broadway
708 Del Prado Blvd. Fort Myers, FL 33901
Cape Coral, FL 33990 USA
USA
RONELLE A. DuBROW, M. D.
PAUL P.CARBONE, M.D., Professor Associate Professor
University of Wisconsin Division of Diagnostic Imaging
Department of Human Oncology and Department of Diagnostic Radiology
Wisconsin Clinical Cancer Center The University of Texas System Cancer
600 Highland Avenue Center
Madison, WI 53792 M. D. Anderson Hospital and Tumor
USA Institute
1515 Holcombe Blvd.
B.J.CUMMINGS, M.B., Ch.B., FRCPC,
Houston, TX 77030
F. R C. R, F. R A. C. R.
USA
Radiation Oncologist, Professor
Department of Radiology RONALD J. F ADELL, M. D.
University of Toronto Department of Radiology
The Princess Margaret Hospital Medical College of Ohio
500 Sherbourne Street 3000 Arlington Avenue
Toronto, Ontario, M4X 1 K9 C.S.l0008
Canada Toledo, OH 43699
USA
LIBERATO J. A. DIDIO, M. D., D. Sc., Ph. D.,
Professor of Anatomy FRANK B. GELDER, Ph. D.
Department of Anatomy Associate Professor of Surgery, Pathology,
Medical College of Ohio and Microbiology IImmunology
3000 Arlington Avenue Director of Clinical Immunology
C.S.l0008 Louisiana State University Medical Center
Toledo, OH 43699 1501 Kings Highway
USA Shreveport, LA 71130
USA
RALPH R DOBELBOWER, JR., M. D., Ph. D.,
F. A. C. R., Professor and Chairman PETER J.GOLDBLATT, M.D.
Department of Radiation Therapy Professor and Chairman
Professor of Neurological Surgery Department of Pathology
(Radiation Therapy) Dean of Graduate School
Medical College of Ohio Medical College of Ohio
3000 Arlington Avenue 3000 Arlington Avenue
C.S.10008 c. S. 10008
Toledo, OH 43699 Toledo, OH 43699
USA USA
VIII List of Contributors
MAHROO HAGHBIN, M. D. JOSEF KORINEK, M. D., Ph. D.
Clinical Assistant Professor of Radiation Section of Gastrointestinal Oncology and
Oncology Digestive Diseases, Division of Medicine
School of Medicine and Dentistry The University of Texas
University of Rochester Medical Center M. D. Anderson Cancer Center, Houston
Rochester, NY 14620 P.O. Box 78,1515 Holcombe Blvd.
USA Houston, TX 77030
USA
E. JOSEPHINE HINSON, R. T. T.
Research Assistant, Daisy Marquis Jones
BERNARD LEVIN, M. D.
Radiation Oncology Center
Section of Gastrointestinal Oncology
Highland Hospital
and Digestive Diseases
1000 South Avenue
Division of Medicine
Rochester, NY 14620
The University of Texas
USA
M. D. Anderson Cancer Center, Houston
P.O. Box 78, 1515 Holcombe Blvd.
JOHN M. How ARD, M. D.
Houston, TX 77030
Professor of Surgery
USA
Department of Surgery
Medical College of Ohio
3000 Arlington Avenue J.H.MEERWALDT, M.D., Ph.D.
c. S. 10008 The Dr. Daniel den Hoed Cancer Center
Toledo, OH 43699 and Rotterdam Radio-Therapeutic Institute
USA Department of Radiotherapy
P. O. Box 5201
MICHAEL 1. KATIN, M. D. 3008 AE Rotterdam
Radiation Therapy Regional Center The Netherlands
Radiation Therapy Associates
3680 Broadway WILLIAM M. MENDENHALL, M. D.
Fort Myers, FL 33901 Associate Professor of Radiation Therapy
USA Department of Radiation Therapy
University of Florida College of Medicine
KITAI KIM, M. D. Box J-385, J. Hillis Miller Health Center
Professor of Pathology Gainesville, FL 32610-0385
Department of Pathology USA
Medical College of Ohio
3000 Arlington Avenue
RODNEY R. MILLION, M. D.
C.S.10008
Professor of Radiation Therapy
Toledo, OH 43699
Department of Radiation Therapy
USA
University of Florida College of Medicine
Box J-385, J. Hillis Miller Health Center
LYDIA KOMARNICKY, M. D.
Gainesville, FL 32610-0385
Department of Radiation Therapy
USA
and Nuclear Medicine
Thomas Jefferson University Hospital
Eleventh and Walnut Street MOHAMMED MOHIUDDIN, M. D.
Philadelphia, PA 19107 Professor of Radiation Therapy
USA and Nuclear Medicine
Department of Radiation Therapy
and Nuclear Medicine
Thomas Jefferson University Hospital
Eleventh and Walnut Street
Philadelphia, PA 19107
USA
List of Contributors IX
VALERIAN B. PINTO, Doctoral Candidate BEN SISCHY, M. D.
Department of MicrobiologyI Immunology Director
Louisiana State University Medical Center Clinical Professor of Radiation Oncology
1501 Kings Highway School of Medicine and Dentistry
Shreveport, LA 71130 University of Rochester Medical Center
USA Daisy Marquis Jones Radiation Oncology
Center
GUILLERMO RAMIREZ, M. D. Highland Hospital
Professor of Oncology 1000 South Avenue
University of Wisconsin Rochester, NY 14620
Department of Human Oncology USA
Wisconsin Clinical Cancer Center
600 Highland Avenue STEVEN M. WAGNER, M. D.
Madison, WI 53792 Clinical Associate Professor
USA of Medicine
Department of Medicine
Medical College of Ohio
3000 Arlington Avenue
C.S.10008
Toledo, OH 43699
USA
Foreword
Primary malignant tumors of the gastrointestinal tract account for 23% of all invasive
cancers and 24% of all the deaths in 1988. In the United States, the American Cancer
Society estimates that there will be 227500 new cases of gastrointestinal malignancy di
agnosed, with 122350 deaths. This includes 9800 new cases of carcinomas of the esopha
gus, 24800 carcinomas of the stomach, 2500 new cases of malignant tumors of the small
intestine, 105000 new cases of tumors of the large intestine, and 42000 new cases of car
cinoma of the rectum, 14000 new cases involving the liver and biliary passages, 27000
new cases of carcinoma of the pancreas, and 2400 other unspecified digestive tract ma
lignancies. This combined incidence is second only to the number of new cases of lung
cancer.
Bleeding from the gastrointestinal tract represents one of the earliest findings with re
gard to malignancy of the gastrointestinal tract. In general, personal or family history of
colon and rectal cancer, personal or family history of polyps in the colon or rectum, or
inflammatory bowel disease are high risk factors with regard to tumors in these loca
tions. Dietary behavior is also important in that a diet high in fat and/or low in fiber
content may be a significant causative factor.
In the assessment of patients with lesions involving the colon and rectum, a rectal ex
amination should be performed every year after the age of 40, and if stool specimens re
veal the presence of blood then a proctosigmoidoscopy should be carried out in order to
precisely define the cause of the rectal bleeding. As the sites of most colorectal cancers
appear to be shifting higher in the colon, the longer flexible instruments that are now
available are required for adequate exploration of the entire colon, which is not possible
with rigid proctoscopes. If abnormalities are found, then more extensive studies such as
colonoscopy, barium enema, etc., should be carried out.
In primary malignant tumors of the esophagus, the onset of symptoms is insidious in
character and unfortunately delays diagnosis. The same is true for primary malignant tu
mors involving the stomach, small intestine, liver and biliary passages, and pancreas. In
these instances, there is a pressing need for appropriate diagnostic studies that would al
low earlier diagnosis. Any insidious symptom relative to esophagitis, dysphagia, abdom
inal pain, discomfort, or distress should be investigated fully in order to define the cause
of the difficulty.
In 1989, the management of malignant tumors involving the gastrointestinal tract has
progressed to where combined integrated multimodal programs of management are ap
propriate for essentially all tumor sites. Surgery plays an important role not only from
the standpoint of diagnosis but in many instances from the standpoint of surgical resec
tion. Oftentimes postoperative radiation therapy is appropriate in the period following
surgical resection. Multidrug systemic chemotherapy is being studied more actively now
in the treatment not only of advanced disease but also in those patients at high risk or
local persistence or recurrence of their disease process.
Various techniques for radiation therapy are finding important applications in malig
nant tumors of the gastrointestinal tract including not only intraluminal placement of ra
dioactive sources in order to boost the radiation dosage beyond that achieved by exter
nal beam radiation therapy but also intraoperative radiation therapy for malignant
tumors of the stomach, pancreas, biliary tree, and retroperitoneal lymph nodes. Intersti-
XII Foreword
tial implantation techniques using radioactive sources are appropriate for certain tumor
sites such as the pancreas.
With the growing number of primary malignant tumors of the digestive tract, more ef
fort is now toward multimodal management than in the past, with gradual progressive
improvement in terms of long-term survival without disease.
The book put forth by Ralph R. Dobelbower, Jr. et al. addresses these questions in
depth and makes recommendations as to appropriate techniques for early diagnosis, tu
mor assessment, and staging as well as treatment procedures.
LUTHER W. BRADY HANS-PETER HEILMANN
Philadelphia Hamburg
