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Risk Factors for Ureteral Stricture After Radiochemotherapy Including Image Guided Adaptive Brachytherapy in Cervical Cancer: Results From the EMBRACE Studies. Int J Radiat Oncol Biol Phys 2019; 103:887-894. [DOI: 10.1016/j.ijrobp.2018.11.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/10/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022]
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Isodose surface volumes in cervix cancer brachytherapy: Change of practice from standard (Point A) to individualized image guided adaptive (EMBRACE I) brachytherapy. Radiother Oncol 2018; 129:567-574. [DOI: 10.1016/j.radonc.2018.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/31/2018] [Accepted: 09/02/2018] [Indexed: 10/28/2022]
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Impact of uncertainties related to noise indicator determination on observed exposure-effect relationship. Noise Health 2018; 20:212-216. [PMID: 30516174 PMCID: PMC6301088 DOI: 10.4103/nah.nah_57_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Noise indicators are the basis to describe noise exposure-effect relationships. The assessment of these noise indicators in field studies includes various uncertainties, so that the true values differ from the determined values used for establishing curve fits. If the relationship between a noise indicator and its effect is nonlinear, uncertainties of the noise indicator modify the observed exposure-effect relationships. MATERIALS AND METHODS The determination of an exposure-relationship curve fit within a field study was simulated based on the assumption of a given true exposure-relationship without uncertainties and normal distributed uncertainties for the observed noise indicator used for the statistics. RESULTS In case of an upward curvature of the exposure-effect relationship, the uncertainty for the noise indicator value leads to an asymmetric effect for the curve fit. Uncertainties of the same amount of over- or underestimation will not result in an identical over- or underestimation of the observed effect. A simulation of this effect shows an increased curvature of the observed curve fit, with overestimated exposure-effect relationships. CONCLUSION Although linear exposure-effect curves are not observed with a systematic shift, quadratic, cubic, and exponential curve forms include a systematic uncertainty in the presented exposure-response curve. If such curves are used to define threshold levels to limit harmful effects of noise, no further uncertainty margins are needed for those situations where the calculated noise indicator uncertainties are equal or lower than those present in the underlying field study.
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Vienna Ii Ring Applicator for Distal Parametrial Disease in Cervical Cancer Image Guided Brachytherapy: Clinical Feasibility and Outcome in a Two-Institutional Setting. Brachytherapy 2018. [DOI: 10.1016/j.brachy.2018.04.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bowel morbidity following radiochemotherapy and image-guided adaptive brachytherapy for cervical cancer: Physician- and patient reported outcome from the EMBRACE study. Radiother Oncol 2018; 127:431-439. [PMID: 29880222 DOI: 10.1016/j.radonc.2018.05.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE This study describes late bowel morbidity prospectively assessed in the multi-institutional EMBRACE study on MRI-guided adaptive brachytherapy in locally advanced cervical cancer (LACC). MATERIALS/METHODS A total of 1176 patients were analyzed. Physician reported morbidity (CTCAE v.3.0) and patient reported outcome (PRO) (EORTC QLQ C30/CX24) were assessed at baseline and at regular follow-up. RESULTS At 3/5 years the actuarial incidence of bowel morbidity grade 3-4 was 5.0%/5.9%, including incidence of stenosis/stricture/fistula of 2.0%/2.6%. Grade 1-2 morbidity was pronounced with prevalence rates of 28-33% during follow-up. Diarrhea and flatulence were most frequently reported, significantly increased after 3 months and remained elevated during follow-up. Incontinence gradually worsened with time. PRO revealed high prevalence rates. Diarrhea ≥"a little" increased from 26% to 37% at baseline to 3 months and remained elevated, difficulty in controlling bowel increased from 11% to 26% at baseline to 3 months gradually worsening with time. Constipation and abdominal cramps improved after treatment. CONCLUSION Bowel morbidity reported in this large cohort of LACC patients was limited regarding severe/life-threatening events. Mild-moderate diarrhea, flatulence and incontinence were prevalent after treatment with PROs indicating a considerable and clinically relevant burden. Critical knowledge based on the extent and manifestation pattern of treatment-related morbidity will serve future patient management.
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Physician assessed and patient reported urinary morbidity after radio-chemotherapy and image guided adaptive brachytherapy for locally advanced cervical cancer. Radiother Oncol 2018; 127:423-430. [PMID: 29784450 DOI: 10.1016/j.radonc.2018.05.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 04/30/2018] [Accepted: 05/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The EMBRACE study is a prospective multi-institutional study on MRI guided adaptive brachytherapy (IGABT) in locally advanced cervix cancer (LACC). This analysis describes early to late urinary morbidity assessed by physicians and patients (PRO). MATERIAL AND METHODS A total of 1176 patients were analysed. Median follow up (FU) was 27 (1-83) months. Morbidity (CTCAE v.3) and PRO (EORTC QLQ-C30&CX24) was prospectively assessed at baseline (BL), and during FU. RESULTS The most frequent symptoms were frequency/urgency, incontinence, and cystitis with grade 2-4 prevalence rates of 4.3%, 5.0% and 1.7% and grade 1-4 prevalence rates of 24.5%, 16.1% and 5.8% at 3-years. The most frequent PRO endpoints were "urinary frequency" and "leaking of urine". Prevalence of "Quite a bit" or "very much" bother fluctuated from 14.0% to 21.5% for "frequency", while "leaking of urine" increased from 4.6% at BL to 9.3% at 3-years. Actuarial 3-year incidence of grade 3-4 urinary morbidity was 5.3% with most events being urinary frequency, incontinence and ureteral strictures. Grade 3-4 fistula, bleeding, spasm and cystitis were all <1.0% at 3/5-years. No grade 5 toxicity occurred. CONCLUSION Urinary grade 3-4 morbidity with IGABT was limited. Urinary morbidity grade 2-4 comprises mainly frequency/urgency, incontinence and cystitis and has considerable prevalence in PRO. Various urinary morbidity endpoints have different patterns of manifestation and time course.
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PV-0260: On the implementation of IGBT for cervix cancer in the observational multicenter study EMBRACE. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30570-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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OC-0391: Evolution of external beam radiotherapy in cervix cancer: from EMBRACE I to EMBRACE II. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30701-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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PO-1016: TRUS/CT for IGABT in cervical cancer: an interobserver study on target volume contouring. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31326-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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60
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OC-0392: Impact of image-guided brachytherapy on pattern of relapse in the RetroEMBRACE cervical cancer study. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30702-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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SP-0351: For the motion (advancement driven by economics). Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30661-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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62
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PV-0252: Image-guided boost brachytherapy for anal canal cancer: tumour and functional outcome. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30562-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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63
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OC-0072: Risk factors for ureteral stricture after IGABT in cervical cancer: results from the EMBRACE studies. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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64
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OC-0396: Late, persistent, substantial and treatment related symptoms (LAPERS): a new metric for late effects. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30706-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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The EMBRACE II study: The outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies. Clin Transl Radiat Oncol 2018; 9:48-60. [PMID: 29594251 PMCID: PMC5862686 DOI: 10.1016/j.ctro.2018.01.001] [Citation(s) in RCA: 391] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 02/07/2023] Open
Abstract
The publication of the GEC-ESTRO recommendations one decade ago was a significant step forward for reaching international consensus on adaptive target definition and dose reporting in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. Since then, IGABT has been spreading, particularly in Europe, North America and Asia, and the guidelines have proved their broad acceptance and applicability in clinical practice. However, a unified approach to volume contouring and reporting does not imply a unified administration of treatment, and currently both external beam radiotherapy (EBRT) and IGABT are delivered using a large variety of techniques and prescription/fractionation schedules. With IGABT, local control is excellent in limited and well-responding tumours. The major challenges are currently loco-regional control in advanced tumours, treatment-related morbidity, and distant metastatic disease. Emerging evidence from the RetroEMBRACE and EMBRACE I studies has demonstrated that clinical outcome is related to dose prescription and technique. The next logical step is to demonstrate excellent clinical outcome with the most advanced EBRT and brachytherapy techniques based on an evidence-based prospective dose and volume prescription protocol. The EMBRACE II study is an interventional and observational multicentre study which aims to benchmark a high level of local, nodal and systemic control while limiting morbidity, using state of the art treatment including an advanced target volume selection and contouring protocol for EBRT and brachytherapy, a multi-parametric brachytherapy dose prescription protocol (clinical validation of dose constraints), and use of advanced EBRT (IMRT and IGRT) and brachytherapy (IC/IS) techniques (clinical validation). The study also incorporates translational research including imaging and tissue biomarkers.
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Dosimetric Studies in Image-Guided Adaptive Brachytherapy in Gynecological Cancers: A Journey to Successful Implementation. J Med Phys 2018. [PMCID: PMC5879828 DOI: 10.4103/jmp.jmp_146_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Artificial neural network based gynaecological image-guided adaptive brachytherapy treatment planning correction of intra-fractional organs at risk dose variation. J Contemp Brachytherapy 2017; 9:508-518. [PMID: 29441094 PMCID: PMC5807998 DOI: 10.5114/jcb.2017.72567] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 12/20/2017] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Intra-fractional organs at risk (OARs) deformations can lead to dose variation during image-guided adaptive brachytherapy (IGABT). The aim of this study was to modify the final accepted brachytherapy treatment plan to dosimetrically compensate for these intra-fractional organs-applicators position variations and, at the same time, fulfilling the dosimetric criteria. MATERIAL AND METHODS Thirty patients with locally advanced cervical cancer, after external beam radiotherapy (EBRT) of 45-50 Gy over five to six weeks with concomitant weekly chemotherapy, and qualified for intracavitary high-dose-rate (HDR) brachytherapy with tandem-ovoid applicators were selected for this study. Second computed tomography scan was done for each patient after finishing brachytherapy treatment with applicators in situ. Artificial neural networks (ANNs) based models were used to predict intra-fractional OARs dose-volume histogram parameters variations and propose a new final plan. RESULTS A model was developed to estimate the intra-fractional organs dose variations during gynaecological intracavitary brachytherapy. Also, ANNs were used to modify the final brachytherapy treatment plan to compensate dosimetrically for changes in 'organs-applicators', while maintaining target dose at the original level. CONCLUSIONS There are semi-automatic and fast responding models that can be used in the routine clinical workflow to reduce individually IGABT uncertainties. These models can be more validated by more patients' plans to be able to serve as a clinical tool.
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Total reference air kerma can accurately predict isodose surface volumes in cervix cancer brachytherapy. A multicenter study. Brachytherapy 2017; 16:1184-1191. [DOI: 10.1016/j.brachy.2017.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 05/17/2017] [Accepted: 05/31/2017] [Indexed: 11/30/2022]
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Increased genitourinary fistula rate after bevacizumab in recurrent cervical cancer patients initially treated with definitive radiochemotherapy and image-guided adaptive brachytherapy. Strahlenther Onkol 2017; 193:1056-1065. [PMID: 28721510 PMCID: PMC5696499 DOI: 10.1007/s00066-017-1178-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/22/2017] [Indexed: 01/15/2023]
Abstract
Background and purpose Patients with recurrent cervical cancer (RecCC) who received definitive radiochemotherapy including image-guided adaptive brachytherapy (IGABT) as primary treatment are currently treated in our institution with palliative intent by chemotherapy (CHT) combined with bevacizumab (BEV). We aim to evaluate the risk of gastrointestinal (GI)/genitourinary (GU) fistula formation in these patients. Materials and methods Data of 35 consecutive patients with RecCC treated initially with radiochemotherapy and IGABT were collected. Known and presumed risk factors associated with fistula formation were evaluated. Fistula rate was compared between patients receiving CHT or CHT+BEV. Results Of the 35 patients, 25 received CHT and 10 patients received CHT+BEV. Clinical characteristics were comparable. Fistulae were reported in 6 patients: two fistulae (8%) in the CHT group, four (40%) in the CHT+BEV group. GU fistula occurred in the CHT+BEV group only (3/4). Of these 6 patients with fistulae, 5 (83%) had undergone previous invasive procedures after the diagnosis of RecCC and 1 patient had undergone pelvic re-irradiation; 3/6 patients had developed a local recurrence. No other risk factors for fistula formation were identified. Conclusion In patients with RecCC after definitive radiochemotherapy including IGABT, the addition of BEV to CHT may increase the risk for GU fistula formation, particularly after invasive pelvic procedures. Future clinical studies are required to identify predictors for fistula formation to subsequently improve patient selection for the addition of BEV in the RecCC setting.
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EP-1790: A balloon applicator with adjustable catheters for image-guided endoluminal rectal brachytherapy. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)32152-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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72
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OC-0051: Fatigue, insomnia, hot flashes (CTCAE) after definitive RCHT+IGABT for cervical cancer (EMBRACE). Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)30495-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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73
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PO-0940: 3D mapping for precise definition of GTV, CTV and their correlation in cervix cancer BT (EMBRACE). Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31377-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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OC-0053: Physician assessed and patient reported limb edema after RCHT + IGABT for cervical cancer (EMBRACE). Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)30497-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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75
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76
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PO-0935: Modeling to compensate for intra-fractional bladder dose variations in gynecological brachytherapy. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31372-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Brachytherapy is a radiotherapy modality associated with a highly focal dose distribution. Brachytherapy treats the cancer tissue from the inside, and the radiation does not travel through healthy tissue to reach the target as with external beam radiotherapy techniques. The nature of brachytherapy makes it attractive for boosting limited size target volumes to very high doses while sparing normal tissues. Significant developments over the last decades have increased the use of 3D image guided procedures with the utilization of CT, MRI, US and PET. This has taken brachytherapy to a new level in terms of controlling dose and demonstrating excellent clinical outcome. Interests in focal, hypofractionated and adaptive treatments are increasing, and brachytherapy has significant potential to develop further in these directions with current and new treatment indications.
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Nodal Failure After Chemoradiation and Magnetic Resonance Imaging Guided Adaptive BT in Cervical Cancer: A Subanalysis Within Embrace. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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79
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Importance of Technique, Dose Prescription, and Contouring in Cervix External Beam Radiation Therapy: Current and Future Practice in a Large Multicenter Study (EMBRACE). Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.1359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Combining transrectal ultrasound and CT for image-guided adaptive brachytherapy of cervical cancer: Proof of concept. Brachytherapy 2016; 15:839-844. [PMID: 27693172 DOI: 10.1016/j.brachy.2016.08.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/16/2016] [Accepted: 08/25/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate the feasibility of a treatment planning workflow for three-dimensional image-guided cervix cancer brachytherapy, combining volumetric transrectal ultrasound (TRUS) for target definition with CT for dose optimization to organs at risk (OARs), for settings with no access to MRI. METHODS AND MATERIALS A workflow for TRUS/CT-based volumetric treatment planning was developed, based on a customized system including ultrasound probe, stepper unit, and software for image volume acquisition. A full TRUS/CT-based workflow was simulated in a clinical case and compared with MR- or CT-only delineation. High-risk clinical target volume was delineated on TRUS, and OARs were delineated on CT. Manually defined tandem/ring applicator positions on TRUS and CT were used as a reference for rigid registration of the image volumes. Treatment plan optimization for TRUS target and CT organ volumes was performed and compared to MRI and CT target contours. RESULTS TRUS/CT-based contouring, applicator reconstruction, image fusion, and treatment planning were feasible, and the full workflow could be successfully demonstrated. The TRUS/CT plan fulfilled all clinical planning aims. Dose-volume histogram evaluation of the TRUS/CT-optimized plan (high-risk clinical target volume D90, OARs D2cm³ for) on different image modalities showed good agreement between dose values reported for TRUS/CT and MRI-only reference contours and large deviations for CT-only target parameters. CONCLUSIONS A TRUS/CT-based workflow for full three-dimensional image-guided cervix brachytherapy treatment planning seems feasible and may be clinically comparable to MRI-based treatment planning. Further development to solve challenges with applicator definition in the TRUS volume is required before systematic applicability of this workflow.
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97: CARO Fellowship Image Guided Brachytherapy in Cervical Cancer: A Comparison Between Intracavitary and Combined Intracavitary/Interstitial Brachytherapy in Regard to Doses to HR CTV, Oars and Late Morbidity – Early Results from the Embrace Study in 999 Patients. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)33496-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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82
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Image guided adaptive brachytherapy with combined intracavitary and interstitial technique improves the therapeutic ratio in locally advanced cervical cancer: Analysis from the retroEMBRACE study. Radiother Oncol 2016; 120:434-440. [DOI: 10.1016/j.radonc.2016.03.020] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 03/08/2016] [Accepted: 03/27/2016] [Indexed: 11/30/2022]
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Can reduction of uncertainties in cervix cancer brachytherapy potentially improve clinical outcome? Radiother Oncol 2016; 120:390-396. [DOI: 10.1016/j.radonc.2016.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/13/2016] [Accepted: 06/19/2016] [Indexed: 11/24/2022]
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Image guided brachytherapy in locally advanced cervical cancer: Improved pelvic control and survival in RetroEMBRACE, a multicenter cohort study. Radiother Oncol 2016; 120:428-433. [DOI: 10.1016/j.radonc.2016.03.011] [Citation(s) in RCA: 371] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/19/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
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A volumetric analysis of GTVD and CTVHR as defined by the GEC ESTRO recommendations in FIGO stage IIB and IIIB cervical cancer patients treated with IGABT in a prospective multicentric trial (EMBRACE). Radiother Oncol 2016; 120:404-411. [DOI: 10.1016/j.radonc.2016.05.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/24/2016] [Accepted: 05/30/2016] [Indexed: 11/24/2022]
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Image Guided Adaptive Brachytherapy in cervix cancer: A new paradigm changing clinical practice and outcome. Radiother Oncol 2016; 120:365-369. [PMID: 27555228 DOI: 10.1016/j.radonc.2016.08.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/17/2022]
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Effect of tumor dose, volume and overall treatment time on local control after radiochemotherapy including MRI guided brachytherapy of locally advanced cervical cancer. Radiother Oncol 2016; 120:441-446. [PMID: 27350396 DOI: 10.1016/j.radonc.2016.05.014] [Citation(s) in RCA: 226] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 05/13/2016] [Accepted: 05/16/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Currently, there is no consensus on dose prescription in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. The purpose of this study was to provide evidence based recommendations for tumor dose prescription based on results from a multi-center patient series (retroEMBRACE). MATERIALS AND METHODS This study analyzed 488 locally advanced cervical cancer patients treated with external beam radiotherapy±chemotherapy combined with IGABT. Brachytherapy contouring and reporting was according to ICRU/GEC-ESTRO recommendations. The Cox Proportional Hazards model was applied to analyze the effect on local control of dose-volume metrics as well as overall treatment time (OTT), dose rate, chemotherapy, and tumor histology. RESULTS With a median follow up of 46months, 43 local failures were observed. Dose (D90) to the High Risk Clinical Target Volume (CTVHR) (p=0.022, HR=0.967 per Gy) was significant for local control, whereas increasing CTVHR volume (p=0.004, HR=1.017 per cm3), and longer OTT (p=0.004, HR=1.023 per day) were associated with worse local control. Histology (p=0.084), chemotherapy (p=0.49) and dose rate (p=1.00) did not have significant impact on local control. Separate analyses according to stage of disease showed that dose to CTVHR, residual gross tumor volume (GTVres), and Intermediate Risk CTV (CTVIR) has significant impact on local control. CONCLUSION CTVHR dose of ⩾85Gy (D90) delivered in 7weeks provides 3-year local control rates of >94% in limited size CTVHR (20cm3), >93% in intermediate size (30cm3) and >86% in large size (70cm3) CTVHR. CTVIR and GTVres dose of ⩾60Gy and ⩾95Gy (D98) leads to similar local control. A dose of 5Gy (CTVHR) is required to compensate an increase of OTT by one week. Increased CTVHR volume by 10cm3 requires additional 5Gy for equivalent local control.
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Value of Magnetic Resonance Imaging Without or With Applicator in Place for Target Definition in Cervix Cancer Brachytherapy. Int J Radiat Oncol Biol Phys 2016; 94:588-97. [PMID: 26867887 DOI: 10.1016/j.ijrobp.2015.09.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 09/09/2015] [Accepted: 09/14/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To define, in the setting of cervical cancer, to what extent information from additional pretreatment magnetic resonance imaging (MRI) without the brachytherapy applicator improves conformity of CT-based high-risk clinical target volume (CTVHR) contours, compared with the MRI for various tumor stages (International Federation of Gynecology and Obstetrics [FIGO] stages I-IVA). METHODS AND MATERIALS The CTVHR was contoured in 39 patients with cervical cancer (FIGO stages I-IVA) (1) on CT images based on clinical information (CTVHR-CTClinical) alone; and (2) using an additional MRI before brachytherapy, without the applicator (CTVHR-CTpre-BT MRI). The CT contours were compared with reference contours on MRI with the applicator in place (CTVHR-MRIref). Width, height, thickness, volumes, and topography were analyzed. RESULTS The CT-MRIref differences hardly varied in stage I tumors (n=8). In limited-volume stage IIB and IIIB tumors (n=19), CTVHR-CTpre-BT MRI-MRIref volume differences (2.6 cm(3) [IIB], 7.3 cm(3) [IIIB]) were superior to CTVHR-CTClinical-MRIref (11.8 cm(3) [IIB], 22.9 cm(3) [IIIB]), owing to significant improvement of height and width (P<.05). In advanced disease (n=12), improved agreement with MR volume, width, and height was achieved for CTVHR-CTpre-BT MRI. In 5 of 12 cases, MRIref contours were partly missed on CT. CONCLUSIONS Pre-BT MRI helps to define CTVHR before BT implantation appropriately, if only CT images with the applicator in place are available for BT planning. Significant improvement is achievable in limited-volume stage IIB and IIIB tumors. In more advanced disease (extensive IIB to IVA), improvement of conformity is possible but may be associated with geographic misses. Limited impact on precision of CTVHR-CT is expected in stage IB tumors.
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Vaginal dose de-escalation in image guided adaptive brachytherapy for locally advanced cervical cancer. Radiother Oncol 2016; 120:480-485. [PMID: 27267048 DOI: 10.1016/j.radonc.2016.05.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 05/15/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Vaginal stenosis is a major problem following radiotherapy in cervical cancer. We investigated a new dose planning strategy for vaginal dose de-escalation (VDD). MATERIALS AND METHODS Fifty consecutive locally advanced cervical cancer patients without lower or middle vaginal involvement at diagnosis from 3 institutions were analysed. External beam radiotherapy was combined with MRI-guided brachytherapy. VDD was obtained by decreasing dwell times in ovoid/ring and increasing dwell times in tandem/needles. The aim was to maintain the target dose (D90 of HR-CTV⩾85Gy EQD2) while reducing the dose to the surface of the vagina to <140% of the physical fractional brachytherapy dose corresponding to a total EQD2 of 85Gy. RESULTS The mean vaginal loading (ovoid/ring) was reduced from 51% to 33% of the total loading with VDD, which significantly reduced the dose to the vaginal dose points (p<0.001) without compromising the target dose. The dose to the ICRU recto-vaginal point was reduced by a mean of 4±4Gy EQD2 (p<0.001), while doses to bladder and rectum (D2cm3) were reduced by 2±2Gy and 3±2Gy, respectively (p<0.001). CONCLUSIONS VDD significantly reduces dose to the upper vagina which is expected to result in reduction of vaginal stenosis.
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90
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Potential role of TRAns Cervical Endosonography (TRACE) in brachytherapy of cervical cancer: proof of concept. J Contemp Brachytherapy 2016; 8:215-20. [PMID: 27504131 PMCID: PMC4965497 DOI: 10.5114/jcb.2016.60502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Magnetic resonance imaging (MRI) is the gold standard for image guided adaptive brachytherapy (BT) of cervical cancer. Ultrasound is an attractive alternative with reasonable costs and high soft tissue depiction quality. This technical note aims to demonstrate the proof of principle for use of TRAns Cervical Endosonography with rotating transducer in the context of brachytherapy (TRACE BT). MATERIAL AND METHODS TRACE BT presentation is based on a single stage IIB cervical cancer patient. Prior to second BT implant, rotating US transducer (6.9 mm diameter) was inserted in cervical canal and axial images obtained at 10 MHz, focal range of 30 mm, and axial resolution of 0.4 mm. Size and topography of hypo-echoic areas were assessed and optimal positions of interstitial needles were determined. Finally, intracavitary applicator was placed and needles inserted through vaginal ring-template according to TRACE pre-plan. MRI-based high risk clinical target volume (CTVHR) dimensions were compared with hypoechoic areas on TRACE. Topography of parametrial needles on post-insertion MRI was compared with TRACE pre-plan. RESULTS Insertion of rotating mechanism into cervico-uterine cavity was safe, feasible and fast. The 360° imaging in axial plane enabled real-time assessment of cervix, uterus, and adjacent parametria. Qualitative comparison of TRACE with post-insertion MRI revealed favorable agreement of findings. In-plane size of CTVHR on MRI was comparable to hypoechoic areas on TRACE. Needle positions on post-insertion MRI corresponded to TRACE-based pre-plan. Main limitation of TRACE was gradual deterioration of image quality due to coupling gel removal. CONCLUSIONS Present proof of concept demonstrates potential role of TRACE-BT for cervical cancer as an attractive high-tech approach with reasonable costs. Prior to investigation of its clinical role, further development of TRACE methodology is needed. This includes reliable transducer-tissue coupling, applicator reconstruction, imaging range, limitations in extensive tumors, US-based contouring concepts, registration with other imaging methods, organ dose-assessment, real-time dosimetry, etc.
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Multicentre evaluation of a novel vaginal dose reporting method in 153 cervical cancer patients. Radiother Oncol 2016; 120:420-427. [PMID: 27237058 DOI: 10.1016/j.radonc.2016.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/27/2016] [Accepted: 05/05/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Recently, a vaginal dose reporting method for combined EBRT and BT in cervical cancer patients was proposed. The current study was to evaluate vaginal doses with this method in a multicentre setting, wherein different applicators, dose rates and protocols were used. MATERIAL AND METHODS In a subset of patients from the EMBRACE study, vaginal doses were evaluated. Doses at the applicator surface left/right and anterior/posterior and at 5mm depth were measured. In addition, the dose at the Posterior-Inferior Border of Symphysis (PIBS) vaginal dose point and PIBS±2cm, corresponding to the mid and lower vagina, was measured. RESULTS 153 patients from seven institutions were included. Large dose variations expressed in EQD2 with α/β=3Gy were seen between patients, in particular at the top left and right vaginal wall (median 195 (range 61-947)Gy/178 (61-980)Gy, respectively). At 5mm depth, doses were 98 (55-212)Gy/91 (54-227)Gy left/right, and 71 (51-145)Gy/67 (49-189)Gy anterior/posterior, respectively. The dose at PIBS and PIBS±2cm was 41 (3-81)Gy, 54 (32-109)Gy and 5 (1-51)Gy, respectively. At PIBS+2cm (mid vagina) dose variation was coming from BT. The variation at PIBS-2cm (lower vagina) was mainly dependent on EBRT field border location. CONCLUSIONS This novel method for reporting vaginal doses coming from EBRT and BT through well-defined dose points gives a robust representation of the dose along the vaginal axis. In addition, it allows comparison of vaginal dose between patients from different centres. The doses at the PIBS points represent the doses at the mid and lower parts of the vagina. Large variations in dose throughout the vagina were observed between patients and centres.
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92
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A comparison of organs at risk doses in GYN intracavitary brachytherapy for different tandem lengths and bladder volumes. J Appl Clin Med Phys 2016; 17:5-13. [PMID: 27167253 PMCID: PMC5690927 DOI: 10.1120/jacmp.v17i3.5584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 12/31/2015] [Accepted: 12/18/2015] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to investigate the concurrent effects of tandem length and bladder volume on dose to pelvic organs at risk (OARs) in HDR intracavitary brachytherapy treatment of cervical cancer. Twenty patients with locally advanced cervical cancer were selected for brachytherapy using Rotterdam applicators. The patients were CT scanned twice with empty and full bladder. Two treatment plans were prepared on each of the image sets. Patients were categorized into two groups; those treated with a tandem length of 4 cm or smaller (T≤4 cm) and those with tandem length larger than 4 cm (T>4 cm). Only one tandem tip angle of 30° was studied. Dose‐volume histograms (DVHs) of OARs were calculated and compared. Bladder dose was significantly affected by both bladder volume and tandem physical length for T≤4 cm. This was reflected on the values obtained for D2cm3, D1cm3, and D0.1cm3 for both empty and full bladder cases. When T>4 cm, no correlation could be established between variations in bladder dose and bladder volume. Rectum dose was generally lower when the bladder was empty and T>4 cm. Dose to sigmoid was increased when T>4 cm; this increase was larger when the bladder was full. Our results suggest that, for tandems longer than 4 cm, keeping the bladder empty may reduce the dose to rectum and sigmoid. This is contrary to cases where a shorter than 4 cm tandem is used in which a full bladder (about 50–120 cm3) tends to result in a lower dose to rectum and sigmoid. Attention should be given to doses to sigmoid with long tandem lengths, as a larger tandem generally results in a larger dose to sigmoid. PACS number(s): 87.53.Jw
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How Accurately Can Total Reference Air Kerma (TRAK) Be Used to Calculate Treatment Volumes in Image (MRI) Guided HDR Cervix Cancer Brachytherapy for Various Clinical Scenarios? Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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94
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Descriptive Analysis of Bladder Morbidity after Definitive Radiotherapy (±Chemotherapy) and Image Guided Adaptive Brachytherapy (IGABT) for Locally Advanced Cervical Cancer. A Report from the EMBRACE Study. Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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95
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Transrectal Ultrasound for Cervix Cancer Brachytherapy: Combining Ultrasound-Based Target Definition and CT-Based Treatment Planning. Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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96
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Image Guided Brachytherapy in Cervical Cancer: A Comparison between Intracavitary and Combined Intracavitary/Interstitial Brachytherapy in Regard to Doses to HR CTV, OARs and Late Morbidity - Early Results from the Embrace Study in 999 Patients. Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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97
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Bowel Morbidity in Locally Advanced Cervical Cancer Patients Treated with Combined External Beam Radiotherapy, Image-Guided Adaptive Brachytherapy (IGABT) and Concomitant Chemotherapy; a Descriptive Analysis from the Embrace Study. Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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98
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Optimum organ volume ranges for organs at risk dose in cervical cancer intracavitary brachytherapy. J Contemp Brachytherapy 2016; 8:135-42. [PMID: 27257418 PMCID: PMC4873556 DOI: 10.5114/jcb.2016.59687] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/14/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To analyze the optimum organ filling point for organs at risk (OARs) dose in cervical cancer high-dose-rate (HDR) brachytherapy. MATERIAL AND METHODS In a retrospective study, 32 locally advanced cervical cancer patients (97 insertions) who were treated with 3D conformal external beam radiation therapy (EBRT) and concurrent chemotherapy during 2010-2013 were included. Rotterdam HDR tandem-ovoid applicators were used and computed tomography (CT) scanning was performed after each insertion. The OARs delineation and GEC-ESTRO-based clinical target volumes (CTVs) contouring was followed by 3D forward planning. Then, dose volume histogram (DVH) parameters of organs were recorded and patients were classified based on their OARs volumes, as well as their inserted tandem length. RESULTS The absorbed dose to point A ranged between 6.5-7.5 Gy. D0.1cm(3) and D2cm(3) of the bladder significantly increased with the bladder volume enlargement (p value < 0.05). By increasing the bladder volume up to about 140 cm(3), the rectum dose was also increased. For the cases with bladder volumes higher than 140 cm(3), the rectum dose decreased. For bladder volumes lower than 75 cm(3), the sigmoid dose decreased; however, for bladder volumes higher than 75 cm(3), the sigmoid dose increased. The D2cm(3) of the bladder and rectum were higher for longer tandems than for shorter ones, respectively. The divergence of the obtained results for different tandem lengths became wider by the extension of the bladder volume. The rectum and sigmoid volume had a direct impact on increasing their D0.1cm(3) and D2cm(3) , as well as decreasing their D10, D30, and D50. CONCLUSIONS There is a relationship between the volumes of OARs and their received doses. Selecting a bladder with a volume of about 70 cm(3) or less proved to be better with regards to the dose to the bladder, rectum, and sigmoid.
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In response to the letter to the editor from Sylvia van Dyk et al. regarding our editorial “High-tech image-guided therapy vs. low-tech, simple, cheap gynecologic brachytherapy”. Brachytherapy 2016; 15:207. [DOI: 10.1016/j.brachy.2015.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
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100
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Dose-effect relationship and risk factors for vaginal stenosis after definitive radio(chemo)therapy with image-guided brachytherapy for locally advanced cervical cancer in the EMBRACE study. Radiother Oncol 2016; 118:160-6. [PMID: 26780997 DOI: 10.1016/j.radonc.2015.12.025] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/22/2015] [Accepted: 12/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE To identify risk factors for vaginal stenosis and to establish a dose-effect relationship for image-guided brachytherapy in locally advanced cervical cancer. MATERIALS/METHODS Patients from the ongoing EMBRACE study with prospectively assessed morbidity (CTCAEv3.0) at baseline and at least one follow-up were selected. Patient-, disease- and treatment characteristics were tested as risk factors for vaginal stenosis G ⩾ 2 in univariate and multivariable analyses (Cox proportional hazards model) and a dose-effect curve was deduced from the estimates. The ICRU rectum point was used to derive the recto-vaginal reference point dose. RESULTS In 630 patients included (median follow-up 24months), 2-year actuarial estimate for vaginal stenosis G ⩾ 2 was 21%. Recto-vaginal reference point dose (HR=1.025, p=0.029), external beam radiotherapy (EBRT) dose >45 Gy/25 fractions (HR=1.770, p=0.056) and tumor extension in the vagina (HR=2.259, p ⩽ 0.001) were risk factors for vaginal stenosis, adjusted for center reporting effects. Based on the model curve, the risk was 20% at 65 Gy, 27% at 75 Gy and 34% at 85 Gy (recto-vaginal reference point dose). CONCLUSION Keeping the EBRT dose at 45 Gy/25 fractions and decreasing the dose contribution of brachytherapy to the vagina decrease the risk of stenosis. A planning aim of ⩽65 Gy EQD2 (EBRT+brachytherapy dose) to the recto-vaginal reference point is therefore proposed.
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