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  • Review Article
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Reducing rectal injury during external beam radiotherapy for prostate cancer

Nature Reviews Urology volume 10, pages 345–357 (2013)Cite this article

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Abstract

Rectal bleeding and faecal incontinence are serious injuries that men with prostate cancer who receive radiotherapy can experience. Although technical advances—including the use of intensity-modulated radiotherapy coupled with image-guided radiotherapy—have enabled the delivery of dose distributions that conform to the shape of the tumour target with steep dose gradients that reduce the dose given to surrounding tissues, radiotherapy-associated toxicity can not be avoided completely. Many large-scale prospective studies have analysed the correlations of patient-related and treatment-related parameters with acute and late toxicity to optimize patient selection and treatment planning. The careful application of dose–volume constraints and the tuning of these constraints to the individual patient's characteristics are now considered the most effective ways of reducing rectal morbidity. Additionally, the use of endorectal balloons (to reduce the margins between the clinical target volume and planning target volume) and the insertion of tissue spacers into the region between the prostate and anterior rectal wall have been investigated as means to further reduce late rectal injury. Finally, some drugs and other compounds are also being considered to help protect healthy tissue. Overall, a number of approaches exist that must be fully explored in large prospective trials to address the important issue of rectal toxicity in prostate cancer radiotherapy.

Key Points

  • Understanding the dose–volume effects involved in rectal injury following pelvic radiotherapy has enabled the development of toxicity models to guide treatment optimization towards favourable dose distributions in the rectum and anal canal

  • Intensity-modulated radiotherapy and image-guided radiotherapy are powerful tools to shape doses and reduce margins between the clinical target volume and planning target volume, reducing normal tissue volumes in the high-dose regions and, consequently, toxicity

  • Endorectal balloons can reduce intrafraction motion and tissue spacers can move the rectum away from the high-dose regions; these tools are beneficial when using external-beam radiotherapy with high doses per fraction

  • Some studies have confirmed that certain patients are remarkably radiosensitive; consequently, clinicians should be particularly vigilant towards patients with predisposing risk factors for rectal toxicity

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Figure 1: Example of dose distribution in a patient with prostate cancer.
Figure 2: Schematic representation of tissue architectures.

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Authors and Affiliations

  1. Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy

    Riccardo Valdagni

  2. Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy

    Riccardo Valdagni & Tiziana Rancati

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  1. Riccardo Valdagni
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  2. Tiziana Rancati
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Both authors researched the data for the article, contributed to the discussion of its content, wrote and edited the manuscript before submission.

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Correspondence to Tiziana Rancati.

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Valdagni, R., Rancati, T. Reducing rectal injury during external beam radiotherapy for prostate cancer. Nat Rev Urol 10, 345–357 (2013). https://doi.org/10.1038/nrurol.2013.96

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