Adaptive radiotherapy of locally advanced sigmoid colon cancer with intra‑fractional motion using the MRIdian system: A case report

Neoadjuvant chemotherapy, when combined with radiotherapy, serves as an optional treatment for patients with locally advanced sigmoid colon cancer and is usually performed in conjunction with complete mesocolic excision. The substantial movement of surrounding organs in cases of sigmoid colon cancer frequently leads to toxicity in normal tissues. The present report details the case of a 76-year-old man diagnosed with locally advanced sigmoid colon cancer. Initially, treatment using the Tomotherapy Hi-Art system was selected; however, during image guidance from the first to the sixth fractions, the tumor location underwent a marked change, exceeding the range of the planning target volume. Efforts to recapture the image were unsuccessful, leading to a decision to transition the patient to the MRIdian system for daily treatment with online adaptive radiotherapy. The positional variations in the tumor were evident in each treatment using the MRIdian system, with mean shifts of 2.58 cm in the right-left direction, 1.24 cm in the cranial-caudal direction and 0.40 cm in the anterior-posterior direction. The mean time from the entry of the patient to treatment completion was 41 min. Adaptive treatment plans were performed for all 19 fractions, with two treatments repeated due to the tumor moving out of tracking range. Following irradiation using the MRIdian system, the gross tumor volume decreased by 62%. Notably, the patient experienced no side effects during treatment. A CT scan conducted 3 months after radiotherapy revealed a marked reduction in the tumor size, consistent with a partial response, leading to the scheduling of surgery. Following surgery, a CT scan after 6 months revealed no local recurrence in the surgical bed region. The findings in the present case support the feasibility of implementing an adaptive treatment plan using the MRIdian system for locally advanced sigmoid colon cancer in the context of neoadjuvant chemoradiotherapy.