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Skipar K, Hompland T, Lund KV, Lindemann K, Hellebust TP, Bruheim K, Lyng H. MRI-guided dynamic risk assessment in cervical cancer based on tumor hypoxia at diagnosis and volume response at brachytherapy. Radiother Oncol 2024; 195:110263. [PMID: 38556173 DOI: 10.1016/j.radonc.2024.110263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND AND PURPOSE Improvements in treatment outcome for patients with locally advanced cervical cancer (LACC) require a better classification of patients according to their risk of recurrence. We investigated whether an imaging-based approach, combining pretreatment hypoxia and tumor response during therapy, could improve risk classification. MATERIAL AND METHODS Ninety-three LACC patients with T2-weigthed (T2W)-, dynamic contrast enhanced (DCE)- and diffusion weighted (DW)-magnetic resonance (MR) images acquired before treatment, and T2W- and, for 64 patients, DW-MR images, acquired at brachytherapy, were collected. Pretreatment hypoxic fraction (HFpre) was determined from DCE- and DW-MR images using the consumption and supply-based hypoxia (CSH)-imaging method. Volume regression at brachytherapy was assessed from T2W-MR images and combined with HFpre. In 17 patients with adequate DW-MR images at brachytherapy, the apparent diffusion coefficient (ADC), reflecting tumor cell density, was calculated. Change in ADC during therapy was combined with volume regression yielding functional regression as explorative response measure. Endpoint was disease free survival (DFS). RESULTS HFpre was the strongest predictor of DFS, but a significant correlation with outcome was found also for volume regression. The combination of HFpre and volume regression showed a stronger association with DFS than HFpre alone. Patients with disease recurrence were selected to either the intermediate- or high-risk group with a 100 % accuracy. Functional regression showed a stronger correlation to HFpre than volume regression. CONCLUSION The combination of pretreatment hypoxia and volume regression at brachytherapy improved patient risk classification. Integration of ADC with volume regression showed promise as a new tumor response parameter.
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Affiliation(s)
- Kjersti Skipar
- Department of Radiation Biology, Oslo University Hospital, Oslo, Norway; Department of Oncology, Telemark Hospital Trust, Skien, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tord Hompland
- Department of Radiation Biology, Oslo University Hospital, Oslo, Norway
| | - Kjersti V Lund
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Kristina Lindemann
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Taran P Hellebust
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Heidi Lyng
- Department of Radiation Biology, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway.
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Parisi S, Sciacca M, Ferrantelli G, Chillari F, Critelli P, Venuti V, Lillo S, Arcieri M, Martinelli C, Pontoriero A, Minutoli F, Ercoli A, Pergolizzi S. Locally advanced squamous cervical carcinoma (M0): management and emerging therapeutic options in the precision radiotherapy era. Jpn J Radiol 2024; 42:354-366. [PMID: 37987880 DOI: 10.1007/s11604-023-01510-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
Squamous cervical carcinoma (SCC) requires particular attention in diagnostic and clinical management. New diagnostic tools, such as (positron emission tomography-magnetic resonance imaging) PET-MRI, consent to ameliorate clinical staging accuracy. The availability of new technologies in radiation therapy permits to deliver higher dose lowering toxicities. In this clinical scenario, new surgical concepts could aid in general management. Lastly, new targeted therapies and immunotherapy will have more room in this setting. The aim of this narrative review is to focus both on clinical management and new therapies in the precision radiotherapy era.
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Affiliation(s)
- S Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - M Sciacca
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - G Ferrantelli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy.
| | - F Chillari
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - P Critelli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - V Venuti
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - S Lillo
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - M Arcieri
- Obstetrics and Gynecology Unit, Department of Human Pathology of Adult and Childhood ``G. Baresi'', University Hospital ``G. Martino'', Messina, Italy
| | - C Martinelli
- Obstetrics and Gynecology Unit, Department of Human Pathology of Adult and Childhood ``G. Baresi'', University Hospital ``G. Martino'', Messina, Italy
| | - A Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - F Minutoli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - A Ercoli
- Obstetrics and Gynecology Unit, Department of Human Pathology of Adult and Childhood ``G. Baresi'', University Hospital ``G. Martino'', Messina, Italy
| | - S Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
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Gong W, Yao Y, Ni J, Jiang H, Jia L, Xiong W, Zhang W, He S, Wei Z, Zhou J. Deep learning-based low-dose CT for adaptive radiotherapy of abdominal and pelvic tumors. Front Oncol 2022; 12:968537. [PMID: 36059630 PMCID: PMC9436420 DOI: 10.3389/fonc.2022.968537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 11/15/2022] Open
Abstract
The shape and position of abdominal and pelvic organs change greatly during radiotherapy, so image-guided radiation therapy (IGRT) is urgently needed. The world’s first integrated CT-linac platform, equipped with fan beam CT (FBCT), can provide a diagnostic-quality FBCT for achieve adaptive radiotherapy (ART). However, CT scans will bring the risk of excessive scanning radiation dose. Reducing the tube current of the FBCT system can reduce the scanning dose, but it will lead to serious noise and artifacts in the reconstructed images. In this study, we proposed a deep learning method, Content-Noise Cycle-Consistent Generative Adversarial Network (CNCycle-GAN), to improve the image quality and CT value accuracy of low-dose FBCT images to meet the requirements of adaptive radiotherapy. We selected 76 patients with abdominal and pelvic tumors who received radiation therapy. The patients received one low-dose CT scan and one normal-dose CT scan in IGRT mode during different fractions of radiotherapy. The normal dose CT images (NDCT) and low dose CT images (LDCT) of 70 patients were used for network training, and the remaining 6 patients were used to validate the performance of the network. The quality of low-dose CT images after network restoration (RCT) were evaluated in three aspects: image quality, automatic delineation performance and dose calculation accuracy. Taking NDCT images as a reference, RCT images reduced MAE from 34.34 ± 5.91 to 20.25 ± 4.27, PSNR increased from 34.08 ± 1.49 to 37.23 ± 2.63, and SSIM increased from 0.92 ± 0.08 to 0.94 ± 0.07. The P value is less than 0.01 of the above performance indicators indicated that the difference were statistically significant. The Dice similarity coefficients (DCS) between the automatic delineation results of organs at risk such as bladder, femoral heads, and rectum on RCT and the results of manual delineation by doctors both reached 0.98. In terms of dose calculation accuracy, compared with the automatic planning based on LDCT, the difference in dose distribution between the automatic planning based on RCT and the automatic planning based on NDCT were smaller. Therefore, based on the integrated CT-linac platform, combined with deep learning technology, it provides clinical feasibility for the realization of low-dose FBCT adaptive radiotherapy for abdominal and pelvic tumors.
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Affiliation(s)
- Wei Gong
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiming Yao
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Ni
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hua Jiang
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lecheng Jia
- Real Time Laboratory, Shenzhen United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, China
| | - Weiqi Xiong
- Radiotherapy Business Unit, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Wei Zhang
- Radiotherapy Business Unit, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Shumeng He
- IRT Laboratory, United Imaging Research Institute of Intelligent Imaging, Beijing, China
| | - Ziquan Wei
- Real Time Laboratory, Shenzhen United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, China
- *Correspondence: Ziquan Wei, ; Juying Zhou,
| | - Juying Zhou
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Ziquan Wei, ; Juying Zhou,
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Morgenthaler J, Köhler C, Budach V, Sehouli J, Stromberger C, Besserer A, Trommer M, Baues C, Marnitz S. Long-term results of robotic radiosurgery for non brachytherapy patients with cervical cancer. Strahlenther Onkol 2020; 197:474-486. [PMID: 32970164 PMCID: PMC8154829 DOI: 10.1007/s00066-020-01685-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Consolidation brachytherapy is a critical treatment component for cervical cancer patients undergoing primary chemoradiation. Some patients are unsuitable for brachytherapy for a variety of reasons. The use of alternatives (LINAC-based stereotactic radiosurgery or external beam boosts) compromise oncologic results in cervical cancer patients. Thus, we evaluated the value of brachytherapy-like doses prescriptions using robotic radiosurgery (CyberKnife®, CR, Acuuray, Sunnyvale, CA, USA). METHODS From 06/2011 to 06/2015, 31 patients (median age 53 years; range 30-77 years) with histologically proven FIGO stages IB-IVB cervical cancer underwent primary chemoradiation. All patients were either not suitable for intracervical brachytherapy for a variety of reasons or refused the brachytherapy. To achieve an adequate dose within the tumor, a CK boost was applied after fiducial implantation. In 29 patients, a dose of either five times 6 Gy or five times 5 Gy was prescribed to the target volume. Two patients received three times 5 Gy. The target dose was prescribed to the 70% isodose. Treatment toxicity was documented once weekly regarding vaginal mucositis, bladder, and bowel irritation according to CTCAE v. 4.03. If possible 3 months after completion of treatment intracervical curettage was performed to exclude residual tumor and the patients were followed up clinically. Sparing of organs at risk (OAR) and outcome in terms of local control (LC), overall survival (OS), and progression-free survival (PFS) were assessed. RESULTS Of the 31 patients, 30 have completed CK boost therapy. The median follow-up time was 40 months (range 5-84 months). General treatment tolerability was good. Except for 1 patient, who had diarrhea grade 3, no treatment related side effects above grade 2 were reported. Sparing of OAR was excellent. The 1‑, 3‑, and 5‑year OS rates were 89, 60, and 57% respectively across all stages. Seven patients showed progression (28%), only two of them with local relapse (8%), resulting in an LC rate of 92% after 3 and 5 years. Mean PFS was 41 months (range 2-84 months). Patients with local recurrence had PFS of 5 and 8 months. Five patients developed distant metastases. Fifteen patients (48%) underwent intracervical curettage 3 months after completion of treatment of which 14 (93%) had complete pathologic response. CONCLUSION Brachytherapy remains the standard of care for patients diagnosed with cervical cancer and indication for primary chemoradiation. In terms of local control, CyberKnife®-based boost concepts provide excellent local control. It can be an alternative for patients who cannot receive adequate brachytherapy. Distant relapse still remains a challenge in this context.
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Affiliation(s)
- Janis Morgenthaler
- Faculty of Medicine and University Hospital Cologne, Department of Radiation Oncology and Cyberknife Center, University of Cologne, Kerpener Str. 62, Cologne, 50937, Germany. .,Center for Integrated Oncology (CIO Köln Bonn), Kerpener Str. 62, Cologne, 50937, Germany.
| | - Christhardt Köhler
- Department of Gynecological Oncology, Asklepios Clinic Hamburg Altona, Paul-Ehrlich-Straße 1, Hamburg, 22763, Germany
| | - Volker Budach
- Department for Radiation Oncology, Campus Virchow-Clinic, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Jalid Sehouli
- Department of Gynecology, Campus Virchow-Clinic, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Berlin, Germany
| | - Carmen Stromberger
- Department for Radiation Oncology, Campus Virchow-Clinic, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Angela Besserer
- Department for Radiation Oncology, Campus Virchow-Clinic, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Maike Trommer
- Faculty of Medicine and University Hospital Cologne, Department of Radiation Oncology and Cyberknife Center, University of Cologne, Kerpener Str. 62, Cologne, 50937, Germany.,Center for Integrated Oncology (CIO Köln Bonn), Kerpener Str. 62, Cologne, 50937, Germany
| | - Christian Baues
- Faculty of Medicine and University Hospital Cologne, Department of Radiation Oncology and Cyberknife Center, University of Cologne, Kerpener Str. 62, Cologne, 50937, Germany.,Center for Integrated Oncology (CIO Köln Bonn), Kerpener Str. 62, Cologne, 50937, Germany
| | - Simone Marnitz
- Faculty of Medicine and University Hospital Cologne, Department of Radiation Oncology and Cyberknife Center, University of Cologne, Kerpener Str. 62, Cologne, 50937, Germany.,Center for Integrated Oncology (CIO Köln Bonn), Kerpener Str. 62, Cologne, 50937, Germany
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5
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Fields EC, Hazell S, Morcos M, Schmidt EJ, Chargari C, Viswanathan AN. Image-Guided Gynecologic Brachytherapy for Cervical Cancer. Semin Radiat Oncol 2020; 30:16-28. [PMID: 31727296 DOI: 10.1016/j.semradonc.2019.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The incorporation of magnetic resonance imaging in brachytherapy has resulted in an increased use of interstitial catheters in order to create a comprehensive treatment plan that covers the visualized tumor. However, the insertion with passive, image-guidance requires estimating the location of the tumor during the insertion process, rather than visualizing and inserting the catheters directly to the desired location under active tracking. In order to treat residual disease, multiparametric MR sequences can enhance the information available to the clinician. The precision availed by MR-guided brachytherapy results in substantial improvements in needle positioning, and resulting treatment plans.
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Affiliation(s)
- Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Sarah Hazell
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Marc Morcos
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Ehud J Schmidt
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave Roussy Cancer Campus, Villejuif, France
| | - Akila N Viswanathan
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD.
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6
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Tan MBBS, MRCP, FRCR, MD LT, Tanderup PhD K, Kirisits PhD C, de Leeuw PhD A, Nout MD, PhD R, Duke MBBS, FRCR S, Seppenwoolde PhD Y, Nesvacil PhD N, Georg PhD D, Kirchheiner PhD K, Fokdal MD, PhD L, Sturdza MD, FRCPC A, Schmid MD M, Swamidas PhD J, van Limbergen MD, PhD E, Haie-Meder MD C, Mahantshetty MD U, Jürgenliemk-Schulz MD, PhD I, Lindegaard DM, DMSc JC, Pötter MD R. Image-guided Adaptive Radiotherapy in Cervical Cancer. Semin Radiat Oncol 2019; 29:284-298. [DOI: 10.1016/j.semradonc.2019.02.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Cree A, Livsey J, Barraclough L, Dubec M, Hambrock T, Van Herk M, Choudhury A, McWilliam A. The Potential Value of MRI in External-Beam Radiotherapy for Cervical Cancer. Clin Oncol (R Coll Radiol) 2018; 30:737-750. [PMID: 30209010 DOI: 10.1016/j.clon.2018.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/02/2018] [Accepted: 08/20/2018] [Indexed: 01/01/2023]
Abstract
The reference standard treatment for cervical cancer is concurrent chemoradiotherapy followed by magnetic resonance imaging (MRI)-guided brachytherapy. Improvements in brachytherapy have increased local control rates, but late toxicity remains high with rates of 11% grade ≥3. The primary clinical target volume (CTV) for external-beam radiotherapy includes the cervix and uterus, which can show significant inter-fraction motion. This means that generous margins are required to cover the primary CTV, increasing the radiation dose to organs at risk and, therefore, toxicity. A number of image-guided radiotherapy techniques (IGRT) have been developed, but motion can be random and difficult to predict prior to treatment. In light of the development of integrated MRI linear accelerators, this review discusses the potential value of MRI in external-beam radiotherapy. Current solutions for managing pelvic organ motion are reviewed, including the potential for online adaptive radiotherapy. The impacts of the use of MRI in tumour delineation and in the delivery of stereotactic ablative body radiotherapy (SABR) are highlighted. The potential role and challenges of using multi parametric MRI to guide radiotherapy are also discussed.
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Affiliation(s)
- A Cree
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - J Livsey
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - L Barraclough
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - M Dubec
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - T Hambrock
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - M Van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - A Choudhury
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - A McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK.
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Palhares DMF, Marconi DG, Azevedo TLD, Hess CB, Fregnani JHTG, Affonso RJ, Veneziani ACLC, Canton HP, Gadia R, Spadim MD, Rossini RR, Kamrava M. Predicting the necessity of adding catheters to intracavitary brachytherapy for women undergoing definitive chemoradiation for locally advanced cervical cancer. Brachytherapy 2018; 17:935-943. [PMID: 30100273 DOI: 10.1016/j.brachy.2018.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/17/2018] [Accepted: 07/03/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE To identify if baseline patient or magnetic resonance imaging (MRI) features can predict which women are at risk for inadequate tumor coverage with only intracavitary tandem and ovoid (T + O) brachytherapy and to correlate tumor coverage with clinical outcomes. METHODS AND MATERIALS We performed a retrospective study of 50 women with cervical cancer treated with chemoradiation at a single institution between January 2014 and December 2015. All patients had a 3T-MRI performed at baseline (MRI1) and at the completion of external beam radiation therapy (MRI2). Gross tumor volume initial (GTV-Tinit) was measured on MRI1 and high-risk clinical tissue volume (CTVHR) on MRI2. CTVHR extending beyond point A was classified as too large for adequate coverage with T + O and requiring interstitial needles. Multivariate analysis was performed to determine predictive factors of inadequate coverage. Kaplan-Meier and Cox Regression were performed to correlate inadequate coverage with outcomes. RESULTS Mean patient age was 49.2 ± 13.2 years, and 84% had Federation of Gynecology and Obstetrics IIB/IIIB disease. Forty-two percent of women were estimated to have inadequate tumor coverage with T + O brachytherapy. The GTV-Tinit volume and dimensions (superior-inferior, left-right, anterior-posterior) on MRI1 were all important predictive factors of inadequate coverage on multivariate analysis. Receiver operating characteristics curves identified optimal thresholds of superior-inferior ≥ 4.5 cm (area under the curve [AUC] = 0.718), left-right ≥ 4.5 cm (AUC = 0.745), anterior-posterior ≥ 5.0 cm (AUC = 0.767), and GTV-Tinit ≥ 85 cm3 (AUC = 0.842). Patients with inadequate coverage had worse clinical outcomes. CONCLUSIONS Baseline MRI tumor size may predict inadequate CTVHR coverage at the time of brachytherapy (i.e., the need for interstitial needles). This may help identify a subset of women requiring early referral to adequately resourced centers to improve clinical outcomes.
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Affiliation(s)
| | - Daniel Grossi Marconi
- Department of Radiation Oncology, Hospital de Câncer de Barretos, Barretos, São Paulo, Brazil
| | | | | | | | - Renato José Affonso
- Department of Radiation Oncology, Hospital de Câncer de Barretos, Barretos, São Paulo, Brazil
| | | | - Heloisa Pelisser Canton
- Department of Radiation Oncology, Hospital de Câncer de Barretos, Barretos, São Paulo, Brazil
| | - Rodrigo Gadia
- Department of Radiation Oncology, Hospital de Câncer de Barretos, Barretos, São Paulo, Brazil
| | - Marcelo Dimas Spadim
- Department of Radiology, Hospital de Câncer de Barretos, Barretos, São Paulo, Brazil
| | | | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, CA
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9
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Chapman CH, Polan D, Vineberg K, Jolly S, Maturen KE, Brock KK, Prisciandaro JI. Deformable image registration–based contour propagation yields clinically acceptable plans for MRI-based cervical cancer brachytherapy planning. Brachytherapy 2018; 17:360-367. [DOI: 10.1016/j.brachy.2017.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/27/2017] [Accepted: 11/30/2017] [Indexed: 11/25/2022]
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10
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Focal boost to residual gross tumor volume in brachytherapy for cervical cancer—A feasibility study. Brachytherapy 2018; 17:181-186. [DOI: 10.1016/j.brachy.2017.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 09/04/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022]
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11
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Peng J, Wang W, Zeng D. Application of magnetic resonance imaging in diagnosis of Uterus Cervical Carcinoma. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2017; 25:205-211. [PMID: 28234273 DOI: 10.3233/xst-17254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Effective treatment of Uterus Cervical Carcinoma (UCC) rely heavily on the precise pre-surgical staging. The conventional International Federation of Gynecology and Obstetrics (FIGO) system based on clinical examination is being applied worldwide for UCC staging. Yet its performance just appears passable. Thus, this study aims to investigate the value of applying Magnetic Resonance Imaging (MRI) with clinical examination in staging of UCC. MATERIALS AND METHODS A retrospective dataset involving 164 patients diagnosed with UCC was enrolled in this study. The mean age of this study population was 46.1 years (range, 28-#x2013;75 years). All patients underwent operations and UCC types were confirmed by pathological examinations. The tumor stages were determined by two experienced Gynecologist independently based on FIGO examinations and MRI. The diagnostic results were also compared with the post-operative pathologic reports. Statistical data analysis on diagnostic performance was then done and reported. RESULTS The study results showed that the overall accuracy of applying MRI in UCC staging was 82.32%, while using FIGO staging method, the staging accuracy was 59.15%. CONCLUSIONS MRI is suitable to evaluate tumor extent with high accuracy, and it can offer more objective information for the diagnosis and staging of UCC. Compared with clinical examinations based on FIGO, MRI illustrated relatively high accuracy in evaluating UCC staging, and is worthwhile to be recommended in future clinical practice.
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Affiliation(s)
- Jidong Peng
- Department of Radiology, Ganzhou People's Hospital, Jiangxi, China
| | - Weiqiang Wang
- Department of Gynecology, The Northwest Women and Children's Hospital, Xi-an, China
| | - Daohui Zeng
- Department of Radiology, First Affiliated Hospital of Guangzhou University of TCM, Guangzhou, Guangdong, China
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12
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Thörnqvist S, Hysing LB, Tuomikoski L, Vestergaard A, Tanderup K, Muren LP, Heijmen BJM. Adaptive radiotherapy strategies for pelvic tumors - a systematic review of clinical implementations. Acta Oncol 2016; 55:943-58. [PMID: 27055486 DOI: 10.3109/0284186x.2016.1156738] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Introdution: Variation in shape, position and treatment response of both tumor and organs at risk are major challenges for accurate dose delivery in radiotherapy. Adaptive radiotherapy (ART) has been proposed to customize the treatment to these motion/response patterns of the individual patients, but increases workload and thereby challenges clinical implementation. This paper reviews strategies and workflows for clinical and in silico implemented ART for prostate, bladder, gynecological (gyne) and ano-rectal cancers. MATERIAL AND METHODS Initial identification of papers was based on searches in PubMed. For each tumor site, the identified papers were screened independently by two researches for selection of studies describing all processes of an ART workflow: treatment monitoring and evaluation, decision and execution of adaptations. Both brachytherapy and external beam studies were eligible for review. RESULTS The review consisted of 43 clinical studies and 51 in silico studies. For prostate, 1219 patients were treated with offline re-planning, mainly to adapt prostate motion relative to bony anatomy. For gyne 1155 patients were treated with online brachytherapy re-planning while 25 ano-rectal cancer patients were treated with offline re-planning, all to account for tumor regression detected by magnetic resonance imaging (MRI)/computed tomography (CT). For bladder and gyne, 161 and 64 patients, respectively, were treated with library-based online plan selection to account for target volume and shape variations. The studies reported sparing of rectum (prostate and bladder cancer), bladder (ano-rectal cancer) and bowel cavity (gyne and bladder cancer) as compared to non-ART. CONCLUSION Implementations of ART were dominated by offline re-planning and online brachytherapy re-planning strategies, although recently online plan selection workflows have increased with the availability of cone-beam CT. Advantageous dosimetric and outcome patterns using ART was documented by the studies of this review. Despite this, clinical implementations were scarce due to challenges in target/organ re-contouring and suboptimal patient selection in the ART workflows.
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Affiliation(s)
- Sara Thörnqvist
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Laura Tuomikoski
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - Anne Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Das S, Samanta S, Mathew M, John R, Peedicayil A, John S. Current Role of Magnetic Resonance Imaging in Evaluation and Radiotherapy in Locally Advanced Carcinoma Cervix. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2016. [DOI: 10.1007/s40944-016-0063-3] [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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14
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Fields EC, Weiss E. A practical review of magnetic resonance imaging for the evaluation and management of cervical cancer. Radiat Oncol 2016; 11:15. [PMID: 26830954 PMCID: PMC4736634 DOI: 10.1186/s13014-016-0591-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/20/2016] [Indexed: 02/06/2023] Open
Abstract
Cervical cancer is a leading cause of mortality in women worldwide. Staging and management of cervical cancer has for many years been based on clinical exam and basic imaging such as intravenous pyelogram and x-ray. Unfortunately, despite advances in radiotherapy and the inclusion of chemotherapy in the standard plan for locally advanced disease, local control has been unsatisfactory. This situation has changed only recently with the increasing implementation of magnetic resonance image (MRI)-guided brachytherapy. The purpose of this article is therefore to provide an overview of the benefits of MRI in the evaluation and management of cervical cancer for both external beam radiotherapy and brachytherapy and to provide a practical approach if access to MRI is limited.
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Affiliation(s)
- Emma C Fields
- Virginia Commonwealth University, Richmond, VA, USA.
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Assessment of Parametrial Response by Growth Pattern in Patients With International Federation of Gynecology and Obstetrics Stage IIB and IIIB Cervical Cancer: Analysis of Patients From a Prospective, Multicenter Trial (EMBRACE). Int J Radiat Oncol Biol Phys 2015; 93:788-96. [DOI: 10.1016/j.ijrobp.2015.08.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 11/19/2022]
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Image-Based Brachytherapy for the Treatment of Cervical Cancer. Int J Radiat Oncol Biol Phys 2015; 92:921-34. [PMID: 26104944 DOI: 10.1016/j.ijrobp.2015.03.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 02/18/2015] [Accepted: 03/12/2015] [Indexed: 11/24/2022]
Abstract
Cervical cancer is a disease that requires considerable multidisciplinary coordination of care and labor in order to maximize tumor control and survival while minimizing treatment-related toxicity. As with external beam radiation therapy, the use of advanced imaging and 3-dimensional treatment planning has generated a paradigm shift in the delivery of brachytherapy for the treatment of cervical cancer. The use of image-based brachytherapy, most commonly with magnetic resonance imaging (MRI), requires additional attention and effort by the treating physician to prescribe dose to the proper volume and account for adjacent organs at risk. This represents a dramatic change from the classic Manchester approach of orthogonal radiographic images and prescribing dose to point A. We reviewed the history and currently evolving data and recommendations for the clinical use of image-based brachytherapy with an emphasis on MRI-based brachytherapy.
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Belfatto A, Riboldi M, Ciardo D, Cattani F, Cecconi A, Lazzari R, Jereczek-Fossa BA, Orecchia R, Baroni G, Cerveri P. Kinetic Models for Predicting Cervical Cancer Response to Radiation Therapy on Individual Basis Using Tumor Regression Measured In Vivo With Volumetric Imaging. Technol Cancer Res Treat 2015; 15:146-58. [PMID: 25759423 DOI: 10.1177/1533034615573796] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/27/2015] [Indexed: 11/15/2022] Open
Abstract
This article describes a macroscopic mathematical modeling approach to capture the interplay between solid tumor evolution and cell damage during radiotherapy. Volume regression profiles of 15 patients with uterine cervical cancer were reconstructed from serial cone-beam computed tomography data sets, acquired for image-guided radiotherapy, and used for model parameter learning by means of a genetic-based optimization. Patients, diagnosed with either squamous cell carcinoma or adenocarcinoma, underwent different treatment modalities (image-guided radiotherapy and image-guided chemo-radiotherapy). The mean volume at the beginning of radiotherapy and the end of radiotherapy was on average 23.7 cm(3) (range: 12.7-44.4 cm(3)) and 8.6 cm(3) (range: 3.6-17.1 cm(3)), respectively. Two different tumor dynamics were taken into account in the model: the viable (active) and the necrotic cancer cells. However, according to the results of a preliminary volume regression analysis, we assumed a short dead cell resolving time and the model was simplified to the active tumor volume. Model learning was performed both on the complete patient cohort (cohort-based model learning) and on each single patient (patient-specific model learning). The fitting results (mean error: ∼ 16% and ∼ 6% for the cohort-based model and patient-specific model, respectively) highlighted the model ability to quantitatively reproduce tumor regression. Volume prediction errors of about 18% on average were obtained using cohort-based model computed on all but 1 patient at a time (leave-one-out technique). Finally, a sensitivity analysis was performed and the data uncertainty effects evaluated by simulating an average volume perturbation of about 1.5 cm(3) obtaining an error increase within 0.2%. In conclusion, we showed that simple time-continuous models can represent tumor regression curves both on a patient cohort and patient-specific basis; this discloses the opportunity in the future to exploit such models to predict how changes in the treatment schedule (number of fractions, doses, intervals among fractions) might affect the tumor regression on an individual basis.
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Affiliation(s)
- Antonella Belfatto
- Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milan, Italy
| | - Marco Riboldi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milan, Italy Bioengineering Unit, Centro Nazionale di Adroterapia Oncologica, Pave, Italy
| | - Delia Ciardo
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Federica Cattani
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Agnese Cecconi
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Roberta Lazzari
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy Department of Health Sciences, University of Milan, Milan, Italy
| | - Roberto Orecchia
- Bioengineering Unit, Centro Nazionale di Adroterapia Oncologica, Pave, Italy Division of Radiotherapy, European Institute of Oncology, Milan, Italy Department of Health Sciences, University of Milan, Milan, Italy
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milan, Italy Bioengineering Unit, Centro Nazionale di Adroterapia Oncologica, Pave, Italy
| | - Pietro Cerveri
- Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milan, Italy Bioengineering Unit, Centro Nazionale di Adroterapia Oncologica, Pave, Italy
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Local experience in cervical cancer imaging: Comparison in tumour assessment between TRUS and MRI. Rep Pract Oncol Radiother 2015; 20:223-30. [PMID: 25949227 DOI: 10.1016/j.rpor.2015.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 09/24/2014] [Accepted: 01/21/2015] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The aim of study was to analyze the accuracy of TRUS (transrectal ultrasound) vs. MRI (magnetic resonance imaging) and clinical gynecological examination estimation in the evaluation of tumor dimensions. METHODS The patients inclusion criterion included primarily pathologically squamous cell carcinoma, but excluded were patients who had not undergone BT (brachytherapy) and treated with palliative intent. We offer two types of treatment for locally advanced cervical cancer: (a) radiochemotherapy followed by surgery and (b) exclusive radiochemotherapy. Imaging tests follow the presence of tumor and tumor size (width and thickness). Each examination was performed by a different physician who had no knowledge of the others' findings. All patients underwent MRI prior to EBRT (external beam radiation therapy) while 18 of them also at the time of the first brachytherapy application. For the analysis we used the r-Pearson correlation coefficient. RESULTS In 2013, 26 patients with cervical cancer were included. A total of 44 gynecological examinations were performed, 44 MRIs and 18 TRUSs. For the comparisons prior to EBRT the correlation coefficient between TRUS vs. MRI was r = 0.79 for AP and r = 0.83 for LL, for GYN vs. MRI was r = 0.6 for AP and r = 0.75 for LL. Prior to BT for GYN vs. MRI, r values were 0.60 and 0.63 for AP and LL, respectively; for GYN vs. TRUS, r values were 0.56 and 0.78 for AP and LL, respectively. CONCLUSIONS A high correlation between the three examinations was obtained. As such, TRUS can be considered a suitable method in the evaluation of tumor dimensions.
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Marnitz S, Schram J, Budach V, Sackerer I, Vercellino GF, Sehouli J, Köhler C. Extended field chemoradiation for cervical cancer patients with histologically proven para-aortic lymph node metastases after laparaoscopic lymphadenectomy. Strahlenther Onkol 2014; 191:421-8. [PMID: 25413986 DOI: 10.1007/s00066-014-0785-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 10/31/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this work was to evaluate the use of extended-field chemoradiation (EFRT) with concomitant chemotherapy in patients with histologically confirmed para-aortic metastases after laparoscopic para-aortic and pelvic lymphadenectomy (LAE) with regard to oncologic results and treatment-related toxicity. PATIENTS AND METHODS A total of 44 women with squamous cell carcinoma (82 %) and adenocarcinoma (18 %) of the cervix in FIGO stages IIA (n = 3), IIB (n = 29); IIIB (n = 9), and IVA (n = 3) and histologically proven para-aortic metastases underwent EFRT and chemotherapy. Laparoscopic LAE was performed in 40 patients. Patients underwent chemoradiation with conventional fractionation of 1.8-50.4 Gy to the para-aortic and pelvic region. In addition, MRI-guided brachytherapy was performed to the cervix with 5-6 single doses of 5 Gy for a total dose of 25-30 Gy. RESULTS The mean number of harvested lymph nodes was 17 in the pelvic as well as para-aortic regions, respectively. Laparoscopic intervention did not delay chemoradiation. Follow-up was 6-76 months (mean 25.1 months). There was no grade 4 or 5 acute radiation toxicity. In all, 8, 4, and 11 % grade 1, 2, and 3 gastrointestinal late toxicities and 7, 11, and 19 % grade 1, 2 and 3 genitourinary late toxicities were recorded. Despite the excellent locoregional (pelvic) control rates of 89.1 and 82.8 % after 2 and 5 years, respectively, the overall survival rates were 68.4 and 54.1 % after 2 and 5 years, respectively. Of the 44 patients, 43 remained tumor free in the para-aortic region. CONCLUSION In patients with proven para-aortic disease, excellent pelvic and para-aortic control could be achieved by laparoscopic LAE followed by EFRT. More than half of the patients were long-term survivors. The high risk of distant metastases should be addressed by further improving systemic treatment.
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Affiliation(s)
- Simone Marnitz
- Department of Radiation Oncology, Charité University Medicine, Augustenburger Platz 1, 13353, Berlin, Germany,
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Murakami N, Kasamatsu T, Wakita A, Nakamura S, Okamoto H, Inaba K, Morota M, Ito Y, Sumi M, Itami J. CT based three dimensional dose-volume evaluations for high-dose rate intracavitary brachytherapy for cervical cancer. BMC Cancer 2014; 14:447. [PMID: 24938757 PMCID: PMC4099086 DOI: 10.1186/1471-2407-14-447] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 06/11/2014] [Indexed: 11/10/2022] Open
Abstract
Background In this study, high risk clinical target volumes (HR-CTVs) according to GEC-ESTRO guideline were contoured retrospectively based on CT images taken at the time of high-dose rate intracavitary brachytherapy (HDR-ICBT) and correlation between clinical outcome and dose of HR-CTV were analyzed. Methods Our study population consists of 51 patients with cervical cancer (Stages IB-IVA) treated with 50 Gy external beam radiotherapy (EBRT) using central shield combined with 2–5 times of 6 Gy HDR-ICBT with or without weekly cisplatin. Dose calculation was based on Manchester system and prescribed dose of 6 Gy were delivered for point A. CT images taken at the time of each HDR-ICBT were reviewed and HR-CTVs were contoured. Doses were converted to the equivalent dose in 2 Gy (EQD2) by applying the linear quadratic model (α/β = 10 Gy). Results Three-year overall survival, Progression-free survival, and local control rate was 82.4%, 85.3% and 91.7%, respectively. Median cumulative dose of HR-CTV D90 was 65.0 Gy (52.7-101.7 Gy). Median length from tandem to the most lateral edge of HR-CTV at the first ICBT was 29.2 mm (range, 18.0-51.9 mm). On univariate analysis, both LCR and PFS was significantly favorable in those patients D90 for HR-CTV was 60 Gy or greater (p = 0.001 and 0.03, respectively). PFS was significantly favorable in those patients maximum length from tandem to edge of HR-CTV at first ICBT was shorter than 3.5 cm (p = 0.042). Conclusion Volume-dose showed a relationship to the clinical outcome in CT based brachytherapy for cervical carcinoma.
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Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji Chuo-ku, Tokyo 104-0045, Japan.
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Robotic radiosurgery as an alternative to brachytherapy for cervical cancer patients. Strahlenther Onkol 2014; 190:538-45. [PMID: 24589918 DOI: 10.1007/s00066-014-0614-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE To compare MRI-guided brachytherapy (BT) and two different dose prescriptions for robotic radiosurgery (RRS) in locally advanced cervical cancer. METHODS AND MATERIALS Eleven patients with FIGO stage IIB-IIIB cervical cancer underwent RRS instead of BT for various reasons. A total dose of 30 Gy was administered in five fractions. The maximum dose was chosen such that the prescribed dose was 70 % of the maximum dose (RRS70). To simulate BT more closely, additional plan calculations were carried out for a higher maximum dose with the same enclosing dose of 30 Gy being now 25 % of the maximum dose (RRS25). BT plans were calculated for the same patients (BTRRS). Finally, the resulting three sets of treatment plans were compared with 38 other patients treated with MRI-guided BT and the same dose prescription (BTref). Plan comparisons were performed based on DVH parameters with regard to target coverage (V100), conformation number (CN), and sparing of the organs at risk (OARs). RESULTS The best coverage of V100 = 100 ± 0 % was obtained with RRS25, followed by RRS70 with 97.1 ± 2.7 %, BTref with 90.9 ± 8.9 %, and the intraindividual BTRRS with 80.6 ± 6.4 %. The sparing of OARs was associated with D0.1 cc, D2 cc, and D5 cc to the rectum, sigmoid, and bladder walls. OAR doses were compliant with the GEC-ESTRO guidelines and comparable among RRS70, RRS25, BTRRS, and BTref. By contrast, RRS25 could not fulfill these guidelines, exceeding considerably the tolerable dose constraints for the walls of the critical OARs. CONCLUSION Despite of the excellent coverage and higher maximum dose, the unacceptably high exposure to the OARs disqualified RRS25 as an alternative for BT in cervical cancer patients. By contrast, RRS70 offered the best protection for the OARs, comparable to BT, and even better target coverage and conformity than BT.
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Distant metastasis in patients with cervical cancer after primary radiotherapy with or without chemotherapy and image guided adaptive brachytherapy. Gynecol Oncol 2014; 133:256-62. [PMID: 24517875 DOI: 10.1016/j.ygyno.2014.02.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 01/09/2014] [Accepted: 02/04/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study is to investigate patterns of distant relapse after primary radiochemotherapy in cervical cancer patients. METHODS All patients with cervical cancer treated in curative intent with external beam radiotherapy +/- chemotherapy and image-guided adaptive brachytherapy between January 1998 and June 2009 at the Medical University of Vienna were included in this retrospective analysis. Patients with locoregional recurrences were excluded from this study. Presence, site of and time to distant metastases were recorded. For identifying prognostic factors, uni- and multivariate analyses using Cox regression analysis were performed. Based on the result from the multivariate analysis, patients were stratified into a high and a low risk group. The Kaplan-Meier method was used to estimate distant-metastasis-free-survival in the overall cohort, in the risk groups and for analysing the impact of chemotherapy within the risk groups. RESULTS A total number of 189 patients were included in this study. After a median follow-up of 54 months, 49 patients developed distant metastases. Overall, distant-metastasis-free-survival 5 years after treatment was 73%. FIGO stage, lymph node status and the extent of tumour regression during treatment were significant predictors for distant metastasis. Distant-metastasis-free-survival 5 years after treatment was 91% and 60% in the low and high risk groups, respectively. The number of the cycles of chemotherapy had a significant impact on the occurrence of distant metastasis in high risk patients, but not in low risk patients. CONCLUSION Patients with high risk factors have a 40% probability of developing distant metastasis within 5 years. In these patients, decreasing the number of cycles of cisplatin may increase their probability of developing distant metastasis.
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Schmid MP, Fidarova E, Pötter R, Petric P, Bauer V, Woehs V, Georg P, Kirchheiner K, Berger D, Kirisits C, Dörr W, Dimopoulos JCA. Magnetic resonance imaging for assessment of parametrial tumour spread and regression patterns in adaptive cervix cancer radiotherapy. Acta Oncol 2013; 52:1384-90. [PMID: 23957566 DOI: 10.3109/0284186x.2013.818251] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To investigate the impact of magnetic resonance imaging (MRI)-morphologic differences in parametrial infiltration on tumour response during primary radiochemotherapy in cervical cancer. MATERIAL AND METHODS Eighty-five consecutive cervical cancer patients with FIGO stages IIB (n = 59) and IIIB (n = 26), treated by external beam radiotherapy (± chemotherapy) and image-guided adaptive brachytherapy, underwent T2-weighted MRI at the time of diagnosis and at the time of brachytherapy. MRI patterns of parametrial tumour infiltration at the time of diagnosis were assessed with regard to predominant morphology and maximum extent of parametrial tumour infiltration and were stratified into five tumour groups (TG): 1) expansive with spiculae; 2) expansive with spiculae and infiltrating parts; 3) infiltrative into the inner third of the parametrial space (PM); 4) infiltrative into the middle third of the PM; and 5) infiltrative into the outer third of the PM. MRI at the time of brachytherapy was used for identifying presence (residual vs. no residual disease) and signal intensity (high vs. intermediate) of residual disease within the PM. Left and right PM of each patient were evaluated separately at both time points. The impact of the TG on tumour remission status within the PM was analysed using χ(2)-test and logistic regression analysis. RESULTS In total, 170 PM were analysed. The TG 1, 2, 3, 4, 5 were present in 12%, 11%, 35%, 25% and 12% of the cases, respectively. Five percent of the PM were tumour-free. Residual tumour in the PM was identified in 19%, 68%, 88%, 90% and 85% of the PM for the TG 1, 2, 3, 4, and 5, respectively. The TG 3-5 had significantly higher rates of residual tumour in the PM in comparison to TG 1 + 2 (88% vs. 43%, p < 0.01). CONCLUSION MRI-morphologic features of PM infiltration appear to allow for prediction of tumour response during external beam radiotherapy and chemotherapy. A predominantly infiltrative tumour spread at the time of diagnosis resulted in a significantly higher rate of residual tumour in the PM at the time of brachytherapy in comparison to a predominantly expansive tumour spread.
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Affiliation(s)
- Maximilian P Schmid
- Department of Radiotherapy, Comprehensive Cancer Center, Medical University of Vienna , Vienna , Austria
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Reduction of rectal doses by removal of gas in the rectum during vaginal cuff brachytherapy. Strahlenther Onkol 2013; 189:951-6. [DOI: 10.1007/s00066-013-0427-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/18/2013] [Indexed: 11/27/2022]
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25
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Time course of late rectal- and urinary bladder side effects after MRI-guided adaptive brachytherapy for cervical cancer. Strahlenther Onkol 2013; 189:535-40. [PMID: 23703404 DOI: 10.1007/s00066-013-0365-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE To analyze the time course of late rectal- and urinary bladder complications after brachytherapy for cervical cancer and to compare the incidence- and prevalence rates thereof. PATIENTS AND METHODS A total of 225 patients were treated with external-beam radiotherapy (EBRT) and magnetic resonance imaging (MRI)-guided brachytherapy with or without chemotherapy. Late side effects were assessed prospectively using the Late Effects in Normal Tissue--Subjective, Objective, Management and Analytic (LENT/SOMA) scale. The parameters analyzed were time to onset, duration, actuarial incidence- (occurrence of new side effects during a defined time period) and prevalence rates (side effects existing at a defined time point). RESULTS Median follow-up was 44 months. Side effects (grade 1-4) in rectum and bladder were present in 31 and 49 patients, 14 and 27 months (mean time to onset) after treatment, respectively. All rectal and 76 % of bladder side effects occurred within 3 years after radiotherapy. Mean duration of rectal events was 19 months; 81 % resolved within 3 years of their initial diagnosis. Mean duration of bladder side effects was 20 months; 61 % resolved within 3 years. The 3- and 5-year actuarial complication rates were 16 and 19 % in rectum and 18 and 28 % in bladder, respectively. The corresponding prevalence rates were 9 and 2 % (rectum) and 18 and 21 % (bladder), respectively. CONCLUSION Late side effects after cervical cancer radiotherapy are partially reversible, but their time course is organ-dependent. The combined presentation of incidence- and prevalence rates provides the most comprehensive information.
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Schmid MP, Pötter R, Brader P, Kratochwil A, Goldner G, Kirchheiner K, Sturdza A, Kirisits C. Feasibility of transrectal ultrasonography for assessment of cervical cancer. Strahlenther Onkol 2012; 189:123-8. [PMID: 23255091 DOI: 10.1007/s00066-012-0258-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 10/18/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE To retrospectively compare the maximum target width and target thickness in patients with locally advanced cervical cancer between magnetic resonance imaging (MRI) and transrectal ultrasonography (TRUS) in the course of primary radiochemotherapy. PATIENTS AND METHODS T2-weighted MRI and TRUS were performed on patients with locally advanced cervical cancer at the same timepoint-either at the time of diagnosis, or at the time of brachytherapy before or after insertion of the applicator. Patients treated from 2009 to 2011 were selected for this study based on the availability of MRI and TRUS at the defined time points. The target was defined as the complete macroscopic tumor mass and the remaining cervix and was measured on transversal planes. Descriptive statistics and a linear regression analysis were performed for the groups. RESULTS Images from 17 patients were available for analysis. Mean maximum target width was 4.2 ± 0.83 cm and 4.2 ± 0.79 cm for MRI and TRUS, respectively. Mean maximum target thickness was 3.3 ± 1.03 cm and 3.1 ± 1.15 cm for MRI and TRUS, respectively. Linear regression analysis for target width and thickness between TRUS and MRI demonstrated a correlation with R(2) = 0.842 and R(2) = 0.943, respectively. CONCLUSION The feasibility of TRUS for the assessment of local target extension could be demonstrated. Comparison of the target width and thickness showed a high correlation between TRUS and MRI, indicating the potential of TRUS for target definition in image-guided adaptive brachytherapy.
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Affiliation(s)
- M P Schmid
- Department of Radiotherapy, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria.
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