Estimation of an optimal radiotherapy utilization rate for gynecologic carcinoma

Robot-assisted Laparoscopic Bilateral Ileal Ureter in Duplex Ureter with Strictures after Treatment Failure of Allium Stents

BACKGROUND

Ureteral injury and vaginal fistula are common complications after surgical treatment and radiotherapy of gynecological tumor^1,2. Ureteral injury in duplex system is more challenging and rarely reported³.

OBJECTIVES

We report our surgical techniques of totally intracorporeal robot-assisted bilateral ileal ureter in a patient who had a bilateral ureteral injury with duplex ureter.

MATERIALS

We present a case of a 61-year-old female who suffered from flank pain and vaginal fistula due to ureteral injury after a radical hysterectomy and radiotherapy for cervical cancer. After repeated ureteral stenting and failure of Allium stent, we performed a bilateral ileal ureter in "7" configuration using robotic assisted laparoscopy. Surgical technique is detailed in the video.

RESULTS

Total operative time was 252 minutes with 100 ml estimated blood loss. The length of ileal segment was 25 cm. There was no conversion to laparoscopic or open surgery. No blood transfusion was required. Left and right abdominal drains were removed on 7^th and 11^th day after the surgery, respectively. The double "J" tubes were removed 2 months later. After 6 months of follow-up, the patient's symptoms were relieved, and the serum creatinine and eGFR were 101.50 μmol/L and 50.418 ml/min·1.73m², respectively. Ultrasound revealed improved mild hydronephrosis. No complications occurred.

CONCLUSION

We successfully performed a totally intracorporeal robotic ileal ureter in "7" configuration. Previous surgical history, radiotherapy, and duplex ureter have increased the difficulty in the reconstruction of ureteral injury. It is necessary to adjust the reconstruction strategy according to the intra-operative findings.

Vaginal cuff brachytherapy for endometrial cancer: a review of major clinical trials with a focus on fractionation

The use of vaginal cuff brachytherapy in the adjuvant management of endometrial cancer has increased over time. Recommendations from the American Brachytherapy Society, American Society of Radiation Oncology, and European Society for Medical Oncology help to guide the application of vaginal cuff brachytherapy. However, wide variation in practice remains regarding treatment techniques. This article reviews the use of vaginal cuff brachytherapy in the post-operative management of endometrial cancer. It covers risk stratification, treatment rationale, outcomes, and treatment planning recommendations with a specific focus on dose-fractionation regimens. The authors performed a thorough literature review of articles pertinent to the goals of this review. Also presented are early results of the Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared with Standard of Care (SAVE) trial of a two-fraction vaginal cuff brachytherapy regimen.

Adjuvant vaginal cuff brachytherapy for early-stage endometrial cancer results in excellent disease control with minimal toxicity. The PORTEC-2 trial showed that vaginal cuff brachytherapy is non-inferior to external beam radiation for vaginal recurrence in patients at high-intermediate risk. Vaginal cuff brachytherapy may also be used as a boost following external beam radiation in combination with chemotherapy for high-risk histologies. Numerous techniques can be used for vaginal cuff brachytherapy, including various medical devices, dose-fractionation schedules, and treatment planning approaches. The early control results of the SAVE trial are promising and we are hopeful that this trial establishes two fraction regimens as a viable option for vaginal cuff brachytherapy.

Education in gynecological brachytherapy

Brachytherapy is an essential component in the curative treatment of many gynecological malignancies. In the past decade, advances in magnetic resonance imaging and the ability to adapt and customize treatment with hybrid interstitial applicators have led to improved clinical outcomes with decreased toxicity. Unfortunately, there has been a shift in clinical practice away from the use of brachytherapy in the United States. The decline in brachytherapy is multifactorial, but includes both a lack of exposure to clinical cases and an absence of standardized brachytherapy training for residents. In other medical specialties, a clear relationship has been established between clinical case volumes and patient outcomes, especially for procedural-based medicine. In surgical residencies, simulation-based medical education (SBME) is a required component of the program to allow for some autonomy before operating on a patient. Within radiation oncology, there is limited but growing experience with SBME for training residents and faculty in gynecological brachytherapy. This review includes single institutional, multi-institutional and national initiatives using creative strategies to teach the components of gynecological brachytherapy. These efforts have measured success in various forms; the majority serve to improve the confidence of the learners, and many have also demonstrated improved competence from the training as well. The American Brachytherapy Society launched the 300 in 10 initiative in 2020 with a plan of training 30 competent brachytherapists per year over a 10 year period and has made great strides with a formal mentorship program as well as externships available to senior residents interested in starting brachytherapy programs. Moving forward, these curricula could be expanded to provide standardized brachytherapy training for all residents. SBME could also play a role in initial certification and maintenance of certification. Given the burden of disease, it would be valuable to develop similar training for providers in low and middle income countries.

Vaginal mucositis in patients with gynaecological cancer undergoing (chemo-)radiotherapy: a retrospective analysis

The objective of this retrospective analysis was to determine the incidence and extent of vaginal mucositis (VM) in women with gynaecological cancer undergoing external (chemo)radiation therapy (CRT). A retrospective analysis was set up to collect data on the incidence and severity of VM in women treated with external pelvic RT for gynaecological cancer at the Jessa Hospital, Hasselt and ZOL, Genk, BE between January 2017 and June 2018. At the start and end of their external (C)RT, they rated the frequency and intensity of five common symptoms of VM. Thirty-three patients treated with RT for gynaecological cancer met the inclusion criteria. A non-negligible proportion of patients already experienced at least one VM symptom to any degree before the start of RT, a proportion that further increased towards the end of the RT (73%). At the end of RT, on average, about 25% of these patients reported moderate-to-severe symptoms (against about 7% before the (C)RT). These results suggest that VM is a rather frequent side effect in gynaecological cancer patients that aggravates during treatment up to a moderate severity level. Although the small sample size, these data highlight the need for attention to VM.Impact StatementWhat is already known about this topic? Radiotherapy plays an important role in the treatment of gynaecological malignancies. A debilitating complication in patients undergoing pelvic radiotherapy is vaginal mucositis, an inflammation of the vaginal mucosal lining. To date, the incidence of vaginal mucositis is still not well documented.What this paper adds? A non-negligible proportion of patients already experienced at least one symptom related to vaginal mucositis before the start of radiotherapy. Most patients presented mild to moderate vaginal mucositis symptoms at the end of external pelvic radiotherapy. Burning sensation, pruritus, and pain were the most frequently documented radiotherapy-induced complications.The implications of this paper: Vaginal mucositis is an underrated side effect of pelvic radiotherapy that needs to be tackled multidisciplinary by a team of nurses, radiotherapists, oncologists, and gynaecologists. The team should tackle the complication from the start of radiotherapy by using the most appropriate measures. Due to a possible link between acute vaginal mucositis and late vaginal toxicity, the team needs to follow-up patient's post-radiotherapy to support patients in late complications and advise/encourage patients in performing vaginal dilatation to prevent vaginal stenosis.

Bilateral ileal ureter substitution for patients with ureteral strictures secondary to gynecological tumors radiotherapy: a multi-center retrospective study

Background

The selection of treatment for bilateral ureteral strictures caused by radiotherapy in patients with gynecological tumors often brings great challenges to urologists. This study was designed to analyze the characteristics of radiation-induced ureteral strictures and summarize the surgical experience of bilateral ileal ureter substitution.

Methods

We retrospectively collected the medical records of 18 patients between June 2010 and June 2019 who had a radiation-induced bilateral ureteral strictures. Time interval from radiotherapy to the discovery of ureteral stricture was categorized into short-term (less than 12 months) and long-term (over 12 months) groups. All patients received reverse “7” bilateral ileal ureteral substitution. Surgical success was defined as no restenosis, relief of symptoms, and improved/stabilized hydronephrosis.

Results

The patients had been suffered from ureteral stricture for a median of 12 [2–106] months. The mean length of the left and right ureteral stricture was 9.6±2.6 and 8.8±3.2 cm, respectively. The mean length of the ileal graft was 29.1±7.4 cm. The mean operative time was 308.4±70.2 min, and the mean estimated blood loss was 254.7±166.2 mL. The postoperative hospital stays in the short-term group was significantly shorter than that in the long-term group (14.0 vs. 20.6 days, P=0.049). During a median follow-up time of 24.1 (4.5–71.9) months, the success rate was 94.4%. Eight minor complications and two major complications occurred in 7 patients.

Conclusions

Bilateral ileal ureter substitution can be an effective strategy for radiation-induced ureteral stricture in patients with gynecological tumors.

Cancer survivorship issues with radiation and hemorrhagic cystitis in gynecological malignancies

PURPOSE

Given that more cancers are being diagnosed earlier and that treatment of cancer is improving, health issues of cancer survivors are becoming more common and apparent. Pelvic radiation therapy for the treatment of gynecological cancers can lead to long-term collateral damage to the bladder, a condition termed radiation cystitis (RC). Late sequelae may take many years to develop and include incontinence and pain as well as hematuria. RC is a rare but potentially life-threatening condition for which there are few management and treatment options.

METHODS

There are limited data in the literature regarding the effects of radiation on the bladder after gynecological cancer therapy and we hereby review the literature on cancer survivorship issues of pelvic radiation for gynecology literature.

RESULTS

Treatment options are available for patients with radiation-induced hemorrhagic cystitis. However, most treatments are risky or only effective for a short timeframe and no therapy is currently available to reverse the disease progress. Furthermore, no standardized guidelines exist describing preferred management options. Common therapies include hyperbaric oxygen therapy, clot evacuation, fulguration, intravesical instillation of astringent agents, and surgery. Novel developing strategies include Botulinum Toxin injections and liposomal-tacrolimus instillations. These treatments and strategies are discussed.

CONCLUSIONS

In this review, we will present current and advanced therapeutic strategies for RC to help cancer survivors deal with long-term bladder health issues.

Urinary incontinence and other pelvic floor disorders after radiation therapy in endometrial cancer survivors

OBJECTIVE

To investigate radiation therapy as a risk factor for urinary or fecal incontinence, pelvic organ prolapse, and sexual dysfunction in endometrial cancer survivors.

STUDY DESIGN

We performed a retrospective cohort study of endometrial cancer survivors. Data were collected using a mailed survey and the medical record. Validated questionnaires were used to generate rates of urinary incontinence and other pelvic floor disorders. The incidence rates of pelvic floor disorders were compared across groups with different exposures to radiation.

RESULTS

Of the 149 endometrial cancer survivors, 41% received radiation therapy. Fifty-one percent of women reported urine leakage. The rates of urinary incontinence in women exposed and not exposed to vaginal brachytherapy (VBT) or whole-pelvis radiation were 48% and 58%, respectively (p=0.47). The incidence of fecal incontinence did not differ between groups, but the score for overall sexual function was significantly higher in women who did not undergo radiation therapy. On multivariable analysis, significant risk factors for urinary incontinence were age (AOR 1.06 95% CI 1.02, 1.10) and BMI (AOR 1.07 95% CI 1.02, 1.11), but treatment with radiation was not significantly associated with urinary incontinence, or fecal incontinence (p>0.05). Age, BMI, and radiation exposure were independent predictors of decreased sexual function score (p<0.01).

CONCLUSION

Local or regional radiation is not associated with urinary or fecal incontinence, but may contribute to sexual dysfunction in endometrial cancer survivors.

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

Evaluating the Role of Urinalysis for Suspected Cystitis in Women Undergoing Pelvic Radiotherapy

PURPOSE

The aims of this study were to analyze the effectiveness of urinalysis parameters in predicting positive urine culture and to characterize urinary tract infections in gynecologic cancer patients receiving pelvic radiotherapy.

METHODS

The records of 134 women receiving pelvic radiotherapy were retrospectively analyzed with a total of 241 urine specimens. Dipstick, urine microscopy, and urine culture data were recorded. Sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratios of dipstick and microscopy components for predicting positive urine culture were calculated. Organisms isolated from positive cultures and their antibiotic resistance data were recorded.

RESULTS

A total of 84 urine cultures (34.9%) were positive for growth. The presence of either urine nitrites, leukocyte esterase, or both had the highest sensitivity (91.7%) of all tested parameters for predicting a positive urine culture. The presence of both urine white blood cells and urine nitrites had the highest specificity (95.5%), positive predictive value (75.0%), and diagnostic odds ratio (7.21 [2.92-17.83]), whereas the absence of urine white blood cells had the highest negative predictive value (87.0%). Escherichia coli was the most common grown in culture, isolated from 19 specimens (22.6%). When antibiotic sensitivity analysis was performed, 23.8% of pathogens were resistant to trimethoprim/sulfamethoxazole, 16.7% were resistant to ciprofloxacin, and 11.1% were resistant to nitrofurantoin.

CONCLUSIONS

Urinalysis may be less accurate for predicting urinary tract infection in women undergoing pelvic RT compared with the general population, but is still useful. Escherichia coli was less common than expected, and the rate of resistance to first-line antibiotics was relatively high, underscoring the importance of culture and sensitivity testing in order to confirm the efficacy of empiric antibiotic therapy.

Local α-tocopherol for acute and short-term vaginal toxicity prevention in patients treated with radiotherapy for gynecologic tumors

INTRODUCTION

Data in literature about the use of adjuvant treatment to reduce acute adverse effects of radiotherapy on the pelvis are scant, with the exception of a few reports on the topical use of estrogen, which promotes proliferation of epithelium.

MATERIALS AND METHODS

In this prospective trial, α-tocopherol acetate was topically administered to patients affected by endometrial and cervical cancer and undergoing radiation treatment to avoid acute vaginal complications.

RESULTS

Vaginal application of α-tocopherol reduced vaginal toxicity and pain, although vaginal secretion was not significantly different in the 2 groups studied. The histological scoring system showed a significant reduction of inflammation, no difference in fibrosis, and an increase of acanthosis.

CONCLUSIONS

The use of α-tocopherol as adjuvant treatment to reduce the acute adverse effects of radiotherapy on the vagina should be considered.

Referral rates and trends in radiotherapy as part of primary treatment of cancer in South Netherlands, 1988–2002

BACKGROUND AND PURPOSE

To study referral rates and time trends in the use of primary radiotherapy (RT).

PATIENTS AND METHODS

The proportion and number of irradiated patients were calculated in a population-based setting among 58,436 cancer patients diagnosed between 1988 and 2002.

RESULTS

The number of patients receiving RT within 6 months of diagnosis (RT6mo) increased by about 3.3% annually, the proportion of all incident cases that received RT6mo remained stable (+/-30%). Only 20% of elderly patients (75+) received RT6mo. The proportion of cancer patients that received RT6mo increased markedly between 1988-1992 and 1998-2002 for patients with prostate cancer (15 and 28%, respectively), rectal cancer (33 and 43%) and brain tumours (48 and 67%). The absolute number of irradiated breast cancer patients increased 30% between 1988 and 2002. Among patients with rectal cancer, a shift occurred from postoperative to preoperative RT since 1995. The percentage of irradiated patients with stage I endometrial cancer decreased from 47% in 1988-1992 to 15% in 1998-2002.

CONCLUSIONS

The percentage of cancer patients who received primary RT remained stable throughout 1988-2002, being consistently lower for older patients. The increased number of irradiated patients was due mainly to earlier detection and the ageing of the population. To clarify the overall percentage of patients irradiated, population-based studies on RT given after 6 months since diagnosis are warranted.

Estimating the optimal radiotherapy utilization for carcinoma of the central nervous system, thyroid carcinoma, and carcinoma of unknown primary origin from evidence-based clinical guidelines

BACKGROUND

In this one in a series of articles, the objective was to estimate the ideal proportion of patients with cancer who should receive radiotherapy at least once during the course of their illness based on the best available evidence. This estimate should be useful in planning for future radiotherapy facilities. Optimal rates of radiotherapy for patients with central nervous system (CNS) carcinoma, thyroid carcinoma, or carcinoma of unknown primary site (CUP) have not been studied previously.

METHODS

A systematic review of evidence-based treatment guidelines for the treatment of CNS carcinoma, CUP, and thyroid carcinoma was undertaken. An optimal radiotherapy utilization tree was constructed for each of these malignancies depicting the indications for radiotherapy at various stages of disease. The proportion of patients who had clinical attributes that indicated a possible benefit from radiotherapy was calculated by adding epidemiological data to the radiotherapy utilization tree. The optimal proportion of patients who should receive radiotherapy was then calculated using specialized decision-analysis software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed.

RESULTS

The optimal rates of radiotherapy utilization for carcinoma of the CNS, thyroid carcinoma, and CUP were 92%, 10%, and 61%, respectively. Comparison with actual rates of utilization in South Australia, Sweden, and the U.S. suggested an under-utilization of radiotherapy for CNS carcinoma and CUP. However, the actual rates of radiotherapy for thyroid carcinoma exceeded the optimal rate for some jurisdictions, although some data may have included radioactive iodine, which was not included in the current project.

CONCLUSIONS

It was possible to estimate optimal radiotherapy utilization rates based on evidence. This methodology allowed a comparison of optimal rates with actual rates to identify areas in which improvements in the evidence-based use of radiotherapy can be made, and it may provide valuable data for future radiotherapy service planning.

The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines

Radiotherapy utilization rates for cancer vary widely internationally. It has previously been suggested that approximately 50% of all cancer patients should receive radiation. However, this estimate was not evidence-based. The aim of this study was to estimate the ideal proportion of new cases of cancer that should receive radiotherapy at least once during the course of their illness based on the best available evidence. An optimal radiotherapy utilization tree was constructed for each cancer based upon indications for radiotherapy taken from evidence-based treatment guidelines. The proportion of patients with clinical attributes that indicated a possible benefit from radiotherapy was obtained by adding epidemiologic data to the radiotherapy utilization tree. The optimal proportion of patients with cancer that should receive radiotherapy was then calculated using TreeAge (TreeAge Software, Williamstown, MA) software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed. The proportion of patients with cancer in whom external beam radiotherapy is indicated according to the best available evidence was calculated to be 52%. Monte Carlo analysis indicated that the 95% confidence limits were from 51.7% to 53.1%. The tightness of the confidence interval suggests that the overall estimate is robust. Comparison with actual radiotherapy utilization data suggests a shortfall in actual radiotherapy delivery. This methodology allows comparison of optimal rates with actual rates to identify areas where improvements in the evidence-based use of radiotherapy can be made. It provides valuable data for radiotherapy service planning. Actual rates need to be addressed to ensure better radiotherapy utilization.

Estimating the optimal utilization rates of radiotherapy for hematologic malignancies from a review of the evidence

BACKGROUND

The objective of this study was to estimate the ideal proportion of new patients with lymphoma who should receive radiotherapy at some time during the course of their illness, based on the best evidence.

METHODS

Available evidence of the efficacy of radiotherapy in most clinical situations for lymphoma were identified through extensive literature reviews and treatment guideline searches. Epidemiologic data concerning the distribution of histologic type, disease stage, and other factors that influence the use of radiotherapy were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiologic data to calculate the optimal proportion of patients who should receive radiotherapy according to the best available evidence. Actual radiotherapy utilization rates also were identified.

RESULTS

The proportion of patients with lymphoma in Australia that should receive radiotherapy at some point in their management, according to the best available evidence, was calculated at 65.0%. Multivariate analysis with a Monte Carlo simulation yielded a radiotherapy utilization rate of 64.4%. The actual utilization rates of radiotherapy for lymphoma reported in clinical practice were 22-29%, substantially lower than the optimal rate calculated in this project.

CONCLUSIONS

Further research will be required to identify why more patients who are diagnosed with lymphoma are not treated with radiotherapy.

Estimation of an optimal external beam radiotherapy utilization rate for head and neck carcinoma

BACKGROUND

Radiotherapy is used commonly in the treatment of patients with head and neck carcinoma. The benchmark radiotherapy utilization rates for head and neck carcinoma largely are unknown. The objective of the current study was to determine the optimal radiotherapy utilization rate for patients with head and neck carcinoma and to compare this optimal rate with actual utilization rates where actual utilization data were available.

METHODS

An optimal radiotherapy utilization tree was constructed that depicted all patients with head and neck carcinoma in whom radiotherapy was indicated according to evidence-based treatment guidelines. The proportions of patients with clinical attributes that indicated possible benefit from radiotherapy were obtained from epidemiological data and were inserted into the utilization tree. The optimal proportion of patients with carcinoma of the head and neck who should receive radiotherapy was calculated by merging the evidence-based recommendations with the epidemiological data in the tree. Optimal rates of radiotherapy utilization were compared with actual rates obtained from population-based studies.

RESULTS

Radiotherapy was indicated at some point during their illness in 74% of all patients with head and neck carcinoma. By subsite, the optimal radiotherapy utilization rates were oral cavity, 74%; lip, 20%; larynx, 100%; oropharynx, 100%; salivary gland, 87%; hypopharynx, 100%; nasopharynx, 100%; paranasal sinuses, 100%; and unknown squamous cell carcinoma of the head and neck, 90%. All treatment recommendations were based on Level III or IV evidence. Assessment of actual radiotherapy utilization rates indicated an increased use of radiotherapy over time for head and neck carcinoma. However, there also were some decreases in the use of radiotherapy for some carcinoma subsites over the past 20 years, despite the lower actual rates compared with the optimal rates. The reasons for these reductions in use were not identified.

CONCLUSIONS

The actual radiotherapy utilization rate for patients with head and neck carcinoma corresponded reasonably closely to the optimal rate for some populations but also identified some shortfalls for other patient groups. The results of this study provide a way of assessing shortfalls in radiotherapy.

Estimating the optimal utilization rates of radiotherapy for hematologic malignancies from a review of the evidence

BACKGROUND

The objective of this study was to estimate the ideal proportion of new patients with leukemia and myeloma who should receive radiotherapy at some time during the course of their illness based on the best evidence.

METHODS

Available evidence of the efficacy of radiotherapy in most clinical situations for leukemia and myeloma was identified through extensive literature reviews and treatment guideline searches. Epidemiologic data concerning the distribution of types, disease stages, and other factors that influence the use of radiotherapy were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiological data to calculate the optimal proportion of patients who should receive radiotherapy according to the best available evidence. Actual radiotherapy utilization rates also were identified.

RESULTS

The proportion of patients diagnosed with myeloma in Australia who should receive radiotherapy based on the evidence was 38%. There was wide variation in the proportion of patients who actually received radiotherapy for myeloma from 24% up to 55%. The recommended proportion of patients diagnosed with myeloma in Australia who, according to the best available evidence, should receive at least a single course of radiotherapy was 38%. The proportion of patients diagnosed in Australia with leukemia who should receive radiotherapy at some point in their management, according to the best available evidence, was calculated at 4%, which corresponded with actual practice.

CONCLUSIONS

Further research will be required to determine why more patients who are diagnosed with myeloma are not treated with radiotherapy.