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DeCesaris C, Wilson T, Kim J, Burt L, Grant J, Harkenrider MM, Huang J, Jhingran A, Kidd E, Konski A, Lin L, Small W, Suneja G, Gaffney D. Financial Improvements From Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared With Standard of Care, "SAVE" Trial. Pract Radiat Oncol 2024:S1879-8500(24)00203-0. [PMID: 39269405 DOI: 10.1016/j.prro.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/04/2024] [Indexed: 09/15/2024]
Abstract
PURPOSE Early-stage endometrial cancer is often treated with hysterectomy followed by adjuvant vaginal cuff brachytherapy (VCB). Financial toxicity from cancer treatment can impact treatment completion. The Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared to Standard of Care trial is a multicenter, prospective randomized trial of standard of care (SoC) VCB doses delivered in 3 to 5 fractions per the physician's discretion compared with a 2-fraction course. We report on secondary cost endpoints, quantifying the financial impacts of shorter treatment courses on institutions and participating patients. METHODS AND MATERIALS Technical (TechCs), professional, and total charges (TotCs) were collected prospectively and are reported as raw and Medicare-adjusted charges per patient. Distance to the treatment center and the median income for each patient's zip code were estimated. The Mann-Whitney U statistic, t test, and X2 test were used to compare characteristics between the 2 groups. RESULTS One hundred eight patients were analyzed. SoC VCB was delivered in 3, 4, and 5 fractions for 27 of 54 patients (50%), 11 of 54 (20%), and 16 of 54 (30%), respectively. The median total distance traveled per patient for SoC versus experimental arms was 213 versus 137 miles (p = .12), and the median cost of commute for patients was $36.3 versus $18.0 (p = .11). Compared with 2-fraction treatment, 5-fraction treatment resulted in longer travel distances (median, 462 vs 137 miles; p < .01) and increased travel costs (median, $59.3 vs $18.0; p ≤ .01). Unadjusted raw professional charges in USD per patient did not differ between SoC versus experimental arms ($9159 vs $7532; p = .19). TechCs were significantly higher in the SoC arm ($35,734 vs $24,696; p ≤ .01), as were TotCs ($44,892 vs $32,228; p < .01;). Medicare-adjusted TechCs and TotCs were higher for the SoC arm. CONCLUSIONS Two-fraction VCB resulted in fewer treatments per patient, reduced cost of travel compared with longer courses, and an adjusted reduction in health care expenditures compared with SoC.
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Affiliation(s)
- Cristina DeCesaris
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Trevor Wilson
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Jaewhan Kim
- Department of Economics, University of Utah, Salt Lake City, Utah
| | - Lindsay Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jonathan Grant
- Department of Radiation Oncology, Intermountain Medical Center, Intermountain Health Care, Murray, Utah
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernadin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anuja Jhingran
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Elizabeth Kidd
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Andre Konski
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lilie Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernadin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - David Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Lu Y, Chen J, Wang F, Zhou Q, Zhang X. A novel multi-channel applicator with a U-shaped channel for vaginal intracavity brachytherapy. J Appl Clin Med Phys 2024:e14521. [PMID: 39259886 DOI: 10.1002/acm2.14521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 08/14/2024] [Accepted: 08/20/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Endometrial cancer is one of the most common gynecological malignancies in the world. Vaginal brachytherapy is an important postoperative adjuvant treatment for endometrial cancer. However, a common problem with existing applicators is insufficient dose at the vaginal apex. PURPOSE This study describes the Hangzhou (HZ) cylinder, a novel 3D printed vaginal intracavity brachytherapy applicator, detailing its characteristics, dose distribution, and clinical applications. METHODS AND MATERIALS The HZ cylinder is distinguished by its unique structure: a U-shaped channel with a 2 mm diameter, a straight central axis channel of the same diameter, and 10 parallel straight channels. For comparison, standard plans were employed, designed to ensure that a minimum of 95% of the prescribed dose reached 5 mm beneath the mucosal surface. We conducted comparative analyses of mucosal surface doses and doses at a 5 mm depth below the mucosa between the HZ cylinder and a conventional single-channel cylinder across various treatment schemes. Additionally, the study examined dose differences in target volume and organs at risk (OARs) between actual HZ cylinder plans and hypothetical single-channel plans. RESULTS In the standard plans, mucosal surface doses at the apex of the vagina were 209.32% and 200.61% of the prescribed dose with the HZ and single-channel cylinders, respectively. The doses on the left and right wall mucosal surfaces varied from 149.26% to 178.13% and 142.98% to 180.75% of the prescribed dose, and on the anterior and posterior wall mucosal surfaces varied from 128.87% to 138.50% and 142.98% to 180.75% of the prescribed dose. Analysis of 24 actual treatment plans revealed that when the vaginal tissue volume dose covering 98% (vaginal D98%) was comparable between the HZ cylinder and virtual single-channel plans (6.74 ± 0.07 Gy vs. 6.69 ± 0.10 Gy, p = 0.24), rectum doses of HZ cylinder plans were significantly lower than those of single-channel plans (D1cc, 5.96 ± 0.56 Gy vs. 6.26 ± 0.71 Gy, p = 0.02 and D2cc, 5.26 ± 0.52 Gy vs. 5.56 ± 0.62 Gy, p = 0.02). CONCLUSIONS The HZ cylinder demonstrates a reduction in dose to the rectum and bladder while maintaining adequate target volume coverage. Its mucosal surface dose is comparable to that of the traditional single-channel cylinder. These findings suggest that the HZ cylinder is a viable and potentially safer alternative for vaginal brachytherapy, warranting further investigation with larger sample sizes.
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Affiliation(s)
- Yanfei Lu
- Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Jianhong Chen
- Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Fangfang Wang
- Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Qiong Zhou
- Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Xiang Zhang
- Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
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Noorian F, Abellana R, Zhang Y, Herreros A, Lancellotta V, Tagliaferri L, Sabater S, Torne A, Agusti-Camprubi E, Rovirosa A. Impact of Vaginal Dilator Use and 68 Gy EQD2 (α/β=3) Dose Constraint on Vaginal Complications in External Beam Irradiation Followed by Brachytherapy in Post-Operative Endometrial Cancer. J Pers Med 2024; 14:838. [PMID: 39202029 PMCID: PMC11355937 DOI: 10.3390/jpm14080838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/08/2024] [Accepted: 08/07/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND This study evaluated the clinical outcomes of applying a 68 Gy EQD2(α/β=3) dose constraint to the most exposed 2 cm3 area of the vagina in post-operative endometrial cancer patients treated with vaginal-cuff brachytherapy after external beam irradiation and the impact of vaginal dilator use on late vaginal complications. MATERIAL AND METHODS We analyzed 131 patients treated with vaginal-cuff brachytherapy after external beam irradiation. Group-1 (65 patients) received one fraction of 7 Gy, and Group-2 (66 patients) received one fraction of between 5.5 and 7.0 Gy after applying a 68 Gy EQD2(α/β=3) dose constraint. Vaginal-cuff relapse, late toxicity, clinical target volume, vaginal dilator use, D90, and EQD2(α/β=3) at 2 cm3 of the most exposed part of the clinical target volume were evaluated. Descriptive analysis, the chi-squared test, Student's t-test, and the Cox proportional and Kaplan-Meier models were used for the statistical analysis. RESULTS With a median follow-up of 60 months, the vaginal-cuff relapse rate was 1/131 (0.8%). Late vaginal complications appeared in 36/65 (55.4%) Group-1 patients and 17/66 (25.8%) Group-2 patients (p = 0.003). Multivariate analysis showed that belonging to Group-1 and vaginal dilator use of <9 months were independent prognostic factors of late vaginal complications with hazard ratios of 1.99 (p = 0.021) and 3.07 (p = 0.010), respectively. CONCLUSIONS A 68 Gy EQD2(α/β=3) constraint at 2 cm3 of clinical target volume and vaginal dilator use of ≥9 months were independent prognostic factors, having protective effects on late vaginal complications.
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Affiliation(s)
- Faegheh Noorian
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
- Radiation Oncology Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Rosa Abellana
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
| | - Yaowen Zhang
- Cancer Center, Henan Provincial People’s Hospital, No.7 Weiwu Road, Zhengzhou 450003, China;
| | - Antonio Herreros
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
- Radiation Oncology Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Valentina Lancellotta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Policlinic Universitario Gemelli, 00168 Rome, Italy; (V.L.); (L.T.)
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Policlinic Universitario Gemelli, 00168 Rome, Italy; (V.L.); (L.T.)
| | - Sebastià Sabater
- Radiation Oncology Department, Hospital General Universitario de Albacete, 02006 Albacete, Spain;
| | - Aureli Torne
- Gynaecological Cancer Unit, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain;
| | - Eduard Agusti-Camprubi
- Radiological Protection Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain;
| | - Angeles Rovirosa
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
- Radiation Oncology Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
- Gynaecological Cancer Unit, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain;
- Institut d’Investigació Biomèdica Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
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George J, Tuli S, Patel PP, Monare B, Ramogola-Masire D, Bazzett-Matabele L, Bvochora-Nsingo M, Chiyapo S, Ralefala T, Vuylsteke P, Rendle KA, Grover S. Delays in Cervical Cancer Treatment Initiation for Patients Living With or Without HIV in Botswana: An Observational Cohort Analysis (2015-2019). Int J Radiat Oncol Biol Phys 2024; 119:1368-1378. [PMID: 38462016 DOI: 10.1016/j.ijrobp.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/04/2024] [Accepted: 02/18/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE To assess delays in treatment initiation of chemoradiation or radiation alone for patients with advanced stage cervical cancer in Botswana. METHODS AND MATERIALS Females with locally advanced cervical cancer (stages IB2-IVB) were prospectively enrolled in an observational cohort study from 2015 to 2019. We evaluated delays at 30, 60, 90, 120, 150, and 180 or greater days between the date of diagnosis and treatment initiation. Factors associated with overall survival were modeled with multivariable Cox proportional hazards regression (aHR). Associations between delays in cervical cancer treatment initiation were evaluated via univariable logistic regression. RESULTS Among the 556 patients included (median age = 47.9 years), 386 (69.4%) were females living with HIV with a median CD4 count of 448.0 cells/μL (IQR, 283.0-647.5 cells/μL) at diagnosis. Most patients had stages 2 (38.1%) or 3 (34.5%) cervical cancer. Early-stage patients experienced longer delays in treatment initiation compared to late-stage patients (P = .033). Early-stage patients with delays ≥90 days and pathology diagnosis between 2016 and 2019 (aHR, 0.34; P < .001) versus <90 days had a decreased risk of mortality, and those with delays ≥90 days and pathology diagnosis before 2016 (aHR, 5.67; P = .022) versus <90 days had an increased risk of mortality. Late-stage patients with delays ≥120 days and pathology diagnosis between 2018 and 2019 (aHR, 1.98; P = .025) versus <120 days had an increased risk of mortality. Early-stage patients with pathology diagnosis between 2016 and 2019 (odds ratio, 2.32; P = .043) versus before 2016 were more likely to experience delays ≥90 days, and late-stage patients who traveled >100 km to the treatment facility (odds ratio, 2.83; P < .001) versus <100 km were more likely to experience delays ≥120 days. CONCLUSIONS Delays in care are common in Botswana, particularly for those living farther from the treatment clinic and at advanced stages. This paper is among the first to show an association between treatment delays and worsened overall survival at advanced stages of cervical cancer, highlighting the need for interventions to help patients receive timely care in global settings.
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Affiliation(s)
- Jessica George
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, California
| | - Shawna Tuli
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, California
| | - Palak P Patel
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | - Lisa Bazzett-Matabele
- Department of Obstetrics & Gynecology, University of Botswana, Gaborone, Botswana; Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | - Peter Vuylsteke
- CHU Namur, Site Sainte-Elisabeth, UCLouvain, Namur, Belgium; Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Katharine A Rendle
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Held KD, McNamara AL, Daartz J, Bhagwat MS, Rothwell B, Schuemann J. Dose Rate Effects from the 1950s through to the Era of FLASH. Radiat Res 2024; 202:161-176. [PMID: 38954556 PMCID: PMC11426361 DOI: 10.1667/rade-24-00024.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/09/2024] [Indexed: 07/04/2024]
Abstract
Numerous dose rate effects have been described over the past 6-7 decades in the radiation biology and radiation oncology literature depending on the dose rate range being discussed. This review focuses on the impact and understanding of altering dose rates in the context of radiation therapy, but does not discuss dose rate effects as relevant to radiation protection. The review starts with a short historic review of early studies on dose rate effects, considers mechanisms thought to underlie dose rate dependencies, then discusses some current issues in clinical findings with altered dose rates, the importance of dose rate in brachytherapy, and the current timely topic of the use of very high dose rates, so-called FLASH radiotherapy. The discussion includes dose rate effects in vitro in cultured cells, in in vivo experimental systems and in the clinic, including both tumors and normal tissues. Gaps in understanding dose rate effects are identified, as are opportunities for improving clinical use of dose rate modulation.
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Affiliation(s)
- Kathryn D Held
- Department of Radiation Oncology, Massachusetts General Hospital Hospital/Harvard Medical School, Boston, Massachusetts 02114
- National Council on Radiation Protection and Measurements, Bethesda, Maryland 20814
| | - Aimee L McNamara
- Department of Radiation Oncology, Massachusetts General Hospital Hospital/Harvard Medical School, Boston, Massachusetts 02114
| | - Juliane Daartz
- Department of Radiation Oncology, Massachusetts General Hospital Hospital/Harvard Medical School, Boston, Massachusetts 02114
| | - Mandar S Bhagwat
- Department of Radiation Oncology, Massachusetts General Hospital Hospital/Harvard Medical School, Boston, Massachusetts 02114
| | - Bethany Rothwell
- Department of Radiation Oncology, Massachusetts General Hospital Hospital/Harvard Medical School, Boston, Massachusetts 02114
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital Hospital/Harvard Medical School, Boston, Massachusetts 02114
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Muangwong P, Tharavichitkul E, Chakrabandhu S, Klunklin P, Onchan W, Jia-Mahasap B, Toapichattrakul P, Nobnop W, Watcharawipha A, Galalae RM, Chitapanarux I. Preliminary results of adjuvant image-guided vaginal brachytherapy alone for early stage endometrial carcinoma. Gynecol Oncol Rep 2024; 54:101423. [PMID: 38846021 PMCID: PMC11153898 DOI: 10.1016/j.gore.2024.101423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 06/09/2024] Open
Abstract
Objective This retrospective study evaluated the preliminary outcomes of image-guided vaginal brachytherapy (IG-VBT) in the adjuvant treatment of high intermediate risk endometrial cancer. Materials and Methods Data were collected from 48 patients who underwent adjuvant IG-VBT between 2019 and 2022 at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University. The vaginal cuff clinical target volume (CTV-VC) is composed of a 4-mm-thick band around vaginal cylinder at the upper 3 cm of the vaginal cuff. A total dose of 21 Gy in three fractions was delivered to the CTV-VC, and the dose to the bladder and rectum were evaluated. Treatment details, patient characteristics, and outcomes were analyzed. Descriptive statistics were used for analysis, and Kaplan-Meier method was employed for survival analysis. Results The mean age was 62 years, with mainly endometrioid carcinoma pathology (96 %). All patients were at stage I, with 87.5 % receiving complete surgical staging. Mean total treatment time was 10 days with mean D90 of CTV-VC was 29.7 Gy, and D2cc of bladder, rectum, and sigmoid were 24.6 Gy, 21.0 Gy, and 7.7 Gy, respectively. At a median follow-up of 37 months, 3-year local control, disease-free survival, and overall survival rates were 100 %, 100 %, and 97.9 %. respectively. Two patients (4.2 %) experienced grade 1-2 gastrointestinal toxicity, while no genitourinary toxicity or serious adverse events were observed. Conclusions The preliminary results of IG-VBT in endometrial cancer demonstrated favorable outcomes in terms of vaginal control and toxicity. Further studies with larger cohorts and longer follow-up durations are warranted.
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Affiliation(s)
- Pooriwat Muangwong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Ekkasit Tharavichitkul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Somvilai Chakrabandhu
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Pitchayaponne Klunklin
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Wimrak Onchan
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Bongkot Jia-Mahasap
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Piyapasara Toapichattrakul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Wannapha Nobnop
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Anirut Watcharawipha
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Razvan M. Galalae
- Faculty of Medicine, Christian-Albrechts-University, Kiel, Germany
- Head of Radiation Oncology Department, Klinikum Bremerhaven, Germany
| | - Imjai Chitapanarux
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
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Wu H, He Y, Chen D, Liu M, Zhao X. High-dose-rate brachytherapy in uterine cervix carcinoma: a comparison of dosimetry and clinical outcomes among three fractionation schedules. Front Oncol 2024; 14:1366323. [PMID: 39070146 PMCID: PMC11272520 DOI: 10.3389/fonc.2024.1366323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Background To assess the differences among three dose-fractionation schedules of image-guided adaptive brachytherapy (IGABT) in cervical squamous cell carcinoma (CSCC) by comparing the dosimetry and clinical outcomes. Methods Forty-five patients with CSCC who underwent chemoradiotherapy and IGABT were retrospectively enrolled and divided into three groups based on their dose-fractionation schedules of brachytherapy as: Group-5.5 (5.5 Gy × 6 fractions), Group-6.0 (6.0 Gy × 5 fractions), and Group-7.0 (7.0 Gy × 4 fractions). The analyzed dose-volume histogram parameters included D90% and D98% of the high-risk clinical target volume (HR-CTV), D90% and D98% of intermediate-risk clinical target volume (IR-CTV), and D0.1cc and D2cc of the organs-at-risk (OARs, namely the bladder, rectum, sigmoid and small intestine). Furthermore, the therapeutic efficacy and late toxicities were also compared among the three groups. Results The doses of HR-CTV and IR-CTV in Group-5.5 were found to be the highest among the three groups, followed by those in Group-6.0. Significant differences were found for the doses of HR-CTV between Group-5.5 and the other groups. There were no significant differences in the bladder, sigmoid and small intestine dose among the three groups. However, Group-6.0 yielded the lowest rectum received doses, with a significant difference in D0.1cc being detected between Group-6.0 and Group-5.5. The median follow-up time was 30.08 months [range, 6.57-46.3]. The numbers of patients with complete response in Group-5.5, Group-6.0 and Group-7.0 were 13, 14 and 14, respectively (P > 0.05). In regard to the toxicitiy, the incidence of radiation cystitis and proctitis in Group-6.0 was lower than that in Group-5.5 and Group-7.0 (P > 0.05). Conclusions The dose-fractionation schedule of 6.0 Gy × 5 fractions provided the most beneficial effects with relatively low OARs doses, suggesting that this dose-fractionation schedule should be prioritized in the clinical application of brachytherapy in cervical cancer.
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Affiliation(s)
- Haiyan Wu
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing, China
- Department of Gynecological Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Yanan He
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Duke Chen
- Department of Gynecological Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Mei Liu
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing, China
- Department of Gynecological Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Xiujuan Zhao
- Department of Gynecological Oncology, Chongqing University Cancer Hospital, Chongqing, China
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Chuk E, Yu C, Scott AA, Liu ZA, Milosevic M, Croke J, Fyles A, Lukovic J, Rink A, Beiki-Ardakani A, Borg J, Skliarenko J, Conway JL, Weersink RA, Han K. Clinical Outcomes of 3 Versus 4 Fractions of Magnetic Resonance Image-Guided Brachytherapy in Cervical Cancer. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00745-4. [PMID: 38936633 DOI: 10.1016/j.ijrobp.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/30/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Magnetic resonance image-guided brachytherapy is essential in the management of locally advanced cervical cancer. This study compares disease and toxicity outcomes in cervical cancer patients treated with 24 Gy/3 fractions (Fr) versus the conventional 28 Gy/4 Fr. METHODS AND MATERIALS This retrospective study included 241 consecutive patients with International Federation of Gynecology and Obstetrics 2018 stage IB to IVA cervical cancer treated with definitive chemoradiation between April 2014 and March 2021. Disease-free survival (DFS) was estimated using the Kaplan-Meier method and compared using the log-rank test. Cumulative incidence of local failure (LF), distant failure (DF), and G2+ gastrointestinal (GI), urinary and vaginal toxicity were estimated using the cumulative incidence function with death as a competing risk and compared using Gray's test. RESULTS Of the 241 patients, 42% received 24 Gy/3 Fr and 58% received 28 Gy/4 Fr. With a median follow-up of 3.2 (range, 0.2-9.2) years, there were 14 local, 41 regional nodal, and 51 distant failures in 63 (26%) patients. No significant differences were found between the 24 Gy/3 Fr and 28 Gy/4 Fr groups in 3-year DFS (77% vs 68%, P = .21), the 3-year cumulative incidence of LF (5% vs 7%, P = .57), DF (22% vs 25%, P = .86), G2+ GI toxicity (11% vs 20%, P = .13), or G2+ vaginal toxicity (14% vs 17%, P = .48), respectively. The 3-year cumulative G2+ urinary toxicity rate was lower in the 24 Gy/3 Fr group (9% vs 23%, P = .03). CONCLUSIONS Patients with cervical cancer treated with 24 Gy/3 Fr had similar DFS, LF, DF, GI, and vaginal toxicity rates and a trend toward a lower G2+ urinary toxicity rate compared with those treated with 28 Gy/4 Fr. A less resource-intensive brachytherapy fractionation schedule of 24 Gy/3 Fr is a safe alternative to 28 Gy/4 Fr for definitive treatment of cervical cancer.
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Affiliation(s)
- Elizabeth Chuk
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Candice Yu
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Aba Anoa Scott
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Michael Milosevic
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Jennifer Croke
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Anthony Fyles
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jelena Lukovic
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alexandra Rink
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Akbar Beiki-Ardakani
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jette Borg
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Julia Skliarenko
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jessica L Conway
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Robert A Weersink
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Kathy Han
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada.
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9
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Stenhouse K, Roumeliotis M, Ciunkiewicz P, Martell K, Quirk S, Banerjee R, Doll C, Phan T, Yanushkevich S, McGeachy P. Prospective validation of a machine learning model for applicator and hybrid interstitial needle selection in high-dose-rate (HDR) cervical brachytherapy. Brachytherapy 2024; 23:368-376. [PMID: 38538415 DOI: 10.1016/j.brachy.2024.02.008] [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: 12/28/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE To Demonstrate the clinical validation of a machine learning (ML) model for applicator and interstitial needle prediction in gynecologic brachytherapy through a prospective clinical study in a single institution. METHODS The study included cervical cancer patients receiving high-dose-rate brachytherapy using intracavitary (IC) or hybrid interstitial (IC/IS) applicators. For each patient, the primary radiation oncologist contoured the high-risk clinical target volume on a pre-brachytherapy MRI, indicated the approximate applicator location, and made a clinical determination of the first fraction applicator. A pre-trained ML model predicted the applicator and IC/IS needle arrangement using tumor geometry. Following the first fraction, ML and radiation oncologist predictions were compared and a replanning study determined the applicator providing optimal organ-at-risk (OAR) dosimetry. The ML-predicted applicator and needle arrangement and the clinical determination were compared to this dosimetric ground truth. RESULTS Ten patients were accrued from December 2020 to October 2022. Compared to the dosimetrically optimal applicator, both the radiation oncologist and ML had an accuracy of 70%. ML demonstrated better identification of patients requiring IC/IS applicators and provided balanced IC and IC/IS predictions. The needle selection model achieved an average accuracy of 82.5%. ML-predicted needle arrangements matched or improved plan quality when compared to clinically selected arrangements. Overall, ML predictions led to an average total improvement of 2.0 Gy to OAR doses over three treatment fractions when compared to clinical predictions. CONCLUSION In the context of a single institution study, the presented ML model demonstrates valuable decision-support for the applicator and needle selection process with the potential to provide improved dosimetry. Future work will include a multi-center study to assess generalizability.
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Affiliation(s)
- Kailyn Stenhouse
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, Alberta, Canada.
| | - Michael Roumeliotis
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD.
| | - Philip Ciunkiewicz
- Department of Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Martell
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Quirk
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada; Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA
| | - Robyn Banerjee
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Corinne Doll
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tien Phan
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Svetlana Yanushkevich
- Department of Electrical and Computer Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Philip McGeachy
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Department of Oncology, University of Calgary, Calgary, Alberta, Canada
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10
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Roach E, Hutten R, Johnson S, Suneja G, Tward J, Petereit D, Gaffney D. The impact of a positive COVID-19 test on timeliness of radiation in patients receiving brachytherapy. Brachytherapy 2024; 23:360-367. [PMID: 38395662 DOI: 10.1016/j.brachy.2024.01.006] [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: 10/22/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Delays in initiating and completing brachytherapy may have adverse oncologic outcomes for patients with cervical, uterine, and prostate cancer. The impact of the COVID-19 pandemic on brachytherapy in the United States has not been well-characterized. OBJECTIVES We aim to evaluate how a positive COVID-19 test affected timeliness of treatment for patients undergoing brachytherapy for cervical, uterine, and prostate cancer. METHODS We queried the National Cancer Database to identify patients diagnosed with cervical, uterine, and prostate cancer in 2019 and 2020 who received brachytherapy in their treatment. Patients who tested positive for COVID-19 between cancer diagnosis and start of radiation were compared to those who did not test positive for COVID-19. Time in days from cancer diagnosis to initiation of radiation was compared using two-sample t-tests with p < 0.05 signifying significant differences. RESULTS We identified 38,341 patients with cervical (n = 6,925), uterine (n = 18,587), and prostate cancer (n = 12,829). Rates of COVID-19 positivity were cervical cancer (n = 135; 2%), uterine cancer (n = 236; 1.3%), and prostate cancer (n = 141; 1%). Of those, 35% of cervical, 49% of uterine, and 43% of prostate cancer patients tested positive between their cancer diagnosis and initiation of radiation. Median days to radiation was significantly longer in these patients: 78 versus 51 for cervical cancer (p < 0.01), 150 versus 104 for uterine cancer (p < 0.01), and 154 versus 124 for prostate cancer (p < 0.01). CONCLUSIONS For patients with cervical, uterine, and prostate cancer diagnosed between 2019-2020, testing positive for COVID-19 after their cancer diagnosis was associated with a delay to initiation of radiation by 4-7 weeks.
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Affiliation(s)
- Eric Roach
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
| | - Ryan Hutten
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI
| | - Skyler Johnson
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jonathan Tward
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - David Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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11
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Hsieh K, Bloom JR, Dickstein DR, Shah A, Yu C, Nehlsen AD, Resende Salgado L, Gupta V, Chadha M, Sindhu KK. Risk-Tailoring Radiotherapy for Endometrial Cancer: A Narrative Review. Cancers (Basel) 2024; 16:1346. [PMID: 38611024 PMCID: PMC11011021 DOI: 10.3390/cancers16071346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Endometrial cancer is the most common gynecologic cancer in the United States and it contributes to the second most gynecologic cancer-related deaths. With upfront surgery, the specific characteristics of both the patient and tumor allow for risk-tailored treatment algorithms including adjuvant radiotherapy and systemic therapy. In this narrative review, we discuss the current radiation treatment paradigm for endometrial cancer with an emphasis on various radiotherapy modalities, techniques, and dosing regimens. We then elaborate on how to tailor radiotherapy treatment courses in combination with other cancer-directed treatments, including chemotherapy and immunotherapy. In conclusion, this review summarizes ongoing research that aims to further individualize radiotherapy regimens for individuals in an attempt to improve patient outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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12
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Takatsu J, Murakami N, Muramoto Y, Karino T, Oshima M, Kosugi Y, Kawamoto T, Terao Y, Shikama N. Safe dose escalation and reduction of the fraction number of uterine cervical brachytherapy using a gel spacer in the rectovaginal and vesicouterine septum: A planning study. Brachytherapy 2024; 23:115-122. [PMID: 38040605 DOI: 10.1016/j.brachy.2023.10.003] [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: 06/14/2023] [Revised: 08/22/2023] [Accepted: 10/06/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE To evaluate the possibility of dose escalation and reduction of fraction number in cervical brachytherapy using a gel spacer. MATERIAL AND METHODS Twenty patients with uterine cervical cancer treated with image-guided adaptive brachytherapy (IGABT) were selected. Hyaluronic acid gel injection (HGI) was performed in the rectovaginal and vesicouterine septum for 10 patients. The other ten patients were not with HGI. Both groups were treated with IGABT involving tandem/ovoid or cylindrical applicators along with additional interstitial needles. Dose distributions approved by radiation oncologists were retrospectively analyzed, and a dose summation of 45 Gy/25 of external beam radiation therapy and IGABT was performed. Dose constraints for D2cc of bladder, rectum, and sigmoid were 80, 70, and 70 Gy, respectively. Equivalent dose in 2-Gy fractions calculations used α/β = 10 Gy for high-risk clinical target volume (CTVHR) D90 and α/β = 3 Gy for organs at risks (OARs). As a planning study, dose distribution rescaling was conducted to deliver as much dose to CTVHR D90 as possible within the dose constraint limitation for OARs when IGABT was performed for four, three, and two fractions in both groups. RESULTS The median CTVHR D90 was >80 Gy in the non-HGI group and >85 Gy in the HGI group for virtual two and three fractions. Rectum D2cc was significantly lower in the HGI group for three fractions (p < 0.01). CONCLUSIONS In the HGI group, adequate dose delivery to CTVHR could be achieved with a reduced IGABT fraction number while meeting the dose constraints of OARs.
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Affiliation(s)
- Jun Takatsu
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
| | - Yoichi Muramoto
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Tatsuki Karino
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
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13
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Dale R, Plataniotis G, Jones B. A generalised method for calculating repopulation-corrected tumour EQD2 values in a wide range of clinical situations, including interrupted treatments. Phys Med 2024; 118:103294. [PMID: 38199178 DOI: 10.1016/j.ejmp.2024.103294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 01/05/2024] [Accepted: 01/07/2024] [Indexed: 01/12/2024] Open
Abstract
Any radiotherapy schedule can be characterised by its 2 Gy per fraction equivalent dose (EQD2). EQD2s are easily calculated for late-responding normal tissues but for tumours significant errors may arise if no allowance is made for any repopulation which occurs in the reference and/or the derived EQD2 schedule. This article presents a systematic approach to calculating tumour EQD2 values utilising the concept of biologically effective dose (BED) with inclusion of repopulation effects. A factor (f) is introduced which allows the inter-dependence between EQD2 and its delivery time (and, hence, the amount of repopulation involved) to be embedded within the formulation without any additional assumptions. There exists a transitional BED below which simple methods of calculating tumour EQD2 remain valid. In cases where simpler approaches are inadequate, the correct EQD2 may be determined from the reference schedule BED (BEDref) by the relationship: EQD2 = A × BEDref - B, where A and B are constants which involve the same radiobiological parameters as are conventionally used in deriving tumour BED values. Some Worked Examples illustrate application of the method to fractionated radiotherapy and indicate that there can be substantial differences with results obtained from using over-simplified approaches. Since reference BEDs are calculable for other types of radiotherapy (brachytherapy, permanent implants, high-LET applications, etc) the methodology allows estimation of tumour EQD2 values in a wide range of clinical circumstances, including cases which involve interrupted treatments.
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Affiliation(s)
- Roger Dale
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK.
| | - Georgios Plataniotis
- Department of Radiation Oncology, Aristoteles University of Thessaloniki, Greece
| | - Bleddyn Jones
- Department of Oncology and Green Templeton College, University of Oxford, UK
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14
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Amjad R, Moldovan N, Raziee H, Leung E, D’Souza D, Mendez LC. Hypofractionated Radiotherapy in Gynecologic Malignancies-A Peek into the Upcoming Evidence. Cancers (Basel) 2024; 16:362. [PMID: 38254851 PMCID: PMC10814353 DOI: 10.3390/cancers16020362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Radiotherapy (RT) has a fundamental role in the treatment of gynecologic malignancies, including cervical and uterine cancers. Hypofractionated RT has gained popularity in many cancer sites, boosted by technological advances in treatment delivery and image verification. Hypofractionated RT uptake was intensified during the COVID-19 pandemic and has the potential to improve universal access to radiotherapy worldwide, especially in low-resource settings. This review summarizes the rationale, the current challenges and investigation efforts, together with the recent developments associated with hypofractionated RT in gynecologic malignancies. A comprehensive search was undertaken using multiple databases and ongoing trial registries. In the definitive radiotherapy setting for cervical cancers, there are several ongoing clinical trials from Canada, Mexico, Iran, the Philippines and Thailand investigating the role of a moderate hypofractionated external beam RT regimen in the low-risk locally advanced population. Likewise, there are ongoing ultra and moderate hypofractionated RT trials in the uterine cancer setting. One Canadian prospective trial of stereotactic hypofractionated adjuvant RT for uterine cancer patients suggested a good tolerance to this treatment strategy in the acute setting, with a follow-up trial currently randomizing patients between conventional fractionation and the hypofractionated dose regimen delivered in the former trial. Although not yet ready for prime-time use, hypofractionated RT could be a potential solution to several challenges that limit access to and the utilization of radiotherapy for gynecologic cancer patients worldwide.
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Affiliation(s)
- Razan Amjad
- Department of Radiation Oncology, King Abdulaziz University, Rabigh 25732, Saudi Arabia
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Nataliya Moldovan
- Department of Radiation Oncology, BC Cancer, Kelowna, BC V1Y 5L3, Canada
| | - Hamid Raziee
- Department of Radiation Oncology, BC Cancer, Kelowna, BC V1Y 5L3, Canada
| | - Eric Leung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - David D’Souza
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Lucas C. Mendez
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
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15
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Washington B, Cheek D, Fabian D, Kudrimoti M, Pokhrel D, Wang C, Thayer-Freeman C, Luo W. Effects of Interfraction Dose Variations of Target and Organs at Risk on Clinical Outcomes in High Dose Rate Brachytherapy for Cervical Cancer. Cancers (Basel) 2023; 15:4862. [PMID: 37835556 PMCID: PMC10571581 DOI: 10.3390/cancers15194862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Meeting dose prescription is critical to control tumors in radiation therapy. Interfraction dose variations (IDVs) from the prescribed dose in high dose rate brachytherapy (HDR) would cause the target dose to deviate from the prescription but their clinical effect has not been widely discussed in the literature. Our previous study found that IDVs followed a left-skewed distribution. The clinical effect of the IDVs in 100 cervical cancer HDR patients will be addressed in this paper. An in-house Monte Carlo (MC) program was used to simulate clinical outcomes by convolving published tumor dose response curves with IDV distributions. The optimal dose and probability of risk-free local control (RFLC) were calculated using the utility model. The IDVs were well-fitted by the left-skewed Beta distribution, which caused a 3.99% decrease in local control probability and a 1.80% increase in treatment failure. Utility with respect to IDV uncertainty increased the RFLC probability by 6.70% and predicted an optimal dose range of 83 Gy-91 Gy EQD2. It was also found that a 10 Gy dose escalation would not affect toxicity. In conclusion, HRCTV IDV uncertainty reduced LC probabilities and increased treatment failure rates. A dose escalation may help mitigate such effects.
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Affiliation(s)
- Brien Washington
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
| | - Dennis Cheek
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
| | - Denise Fabian
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
| | - Mahesh Kudrimoti
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
| | - Damodar Pokhrel
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
| | - Chi Wang
- Department of Internal Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA;
| | - Cameron Thayer-Freeman
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
| | - Wei Luo
- Department of Radiation Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; (B.W.); (D.C.); (D.F.); (M.K.); (D.P.); (C.T.-F.)
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16
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Gutiérrez Miguélez C, Rodríguez Villalba S, Villafranca Iturre E, Fuentemilla Urio N, Richart Sancho J, Córdoba Lago S, Pino Sorroche F, Gracia Lucio R, Herreros Martínez A, Najjari-Jamal D. Recommendations of the Spanish brachytherapy group of the Spanish Society of Radiation Oncology and the Spanish Society of Medical Physics for interstitial high-dose-rate brachytherapy for gynaecologic malignancies. Clin Transl Oncol 2023; 25:912-932. [PMID: 36445642 PMCID: PMC10025210 DOI: 10.1007/s12094-022-03016-1] [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: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 12/02/2022]
Abstract
The present document includes consensus-based recommendations from the Brachytherapy Group (GEB) of the Spanish Society of Radiation Oncology (SEOR) and the Spanish Society of Medical Physics (SEFM) for interstitial high-dose-rate (HDR) brachytherapy (BT) for gynaecologic malignancies. A nine-item survey-which included questions on experience with interstitial BT; indications and technique; applicator type; magnetic resonance imaging (MRI)-based planning; dose; fractionation schedule; and treatment planning-was sent to all radiation oncology departments (n = 174) in Spain in 2021. Responses were received from 36 centres (50% of all centres [n = 72] with a BT unit). The consensus-based recommendations presented here are based on a review of the available literature, professional experience among the group of experts, and in-person discussions held during the annual meeting of these two societies. We describe the results of the survey and the following: indications; contraindications; patient selection; description of applicators; role of imaging in planning; contouring; dose prescription; dosimetric reconstruction; optimisation; and dose indications for cancers of the cervix, vagina, and vulva. The various clinical scenarios in which interstitial BT is used in the treatment of gynaecological tumours are described in detail, including cervix intracavitary/interstitial hybrid HDR-BT; cervix perineal templates/freehand implants; primary vaginal malignancies/vaginal recurrences; and vulvar interstitial implants.
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Affiliation(s)
- Cristina Gutiérrez Miguélez
- Radiation Oncology Department, Institut Català d'Oncologia, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB) Catalonia, Hospitalet de Llobregat, Spain.
| | | | | | | | - Jose Richart Sancho
- Radiation Oncology Department, Hospital Clínica Benidorm, Benidorm, Spain
- Radiation Oncology Department, Hospital Universitario San Juan, Alicante, Spain
| | - Sofía Córdoba Lago
- Radiation Oncology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Francisco Pino Sorroche
- Radiophysics Department, Institut Català d'Oncologia, Hospitalet de Llobregat, Catalonia, Spain
| | - Ruth Gracia Lucio
- Radiophysics Department, Institut Català d'Oncologia, Hospitalet de Llobregat, Catalonia, Spain
| | | | - Dina Najjari-Jamal
- Radiation Oncology Department, Institut Català d'Oncologia, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB) Catalonia, Hospitalet de Llobregat, Spain
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17
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Li B, Hirata E, Trejo JM, Garcia B, Chang B, Malhotra S, Ning M, Sarria GJ. Exploring the Cost of Radiation Therapy Delivery for Locally Advanced Cervical Cancer in a Public and a Private Center in Latin America Using Time-Driven Activity-Based Costing. Int J Radiat Oncol Biol Phys 2023; 115:1205-1216. [PMID: 36922083 DOI: 10.1016/j.ijrobp.2022.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 11/04/2022] [Accepted: 11/30/2022] [Indexed: 03/14/2023]
Affiliation(s)
- Benjamin Li
- Department of Radiation Oncology, University of California, San Francisco, California; Rayos Contra Cancer, San Francisco, California.
| | - Emily Hirata
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Juan Manuel Trejo
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Bertha Garcia
- Department of Radiotherapy, AUNA Clinica Delgado, Lima, Peru
| | - Betty Chang
- Rayos Contra Cancer, San Francisco, California; University of Illinois College of Medicine, Chicago, Illinois
| | - Sameeksha Malhotra
- Rayos Contra Cancer, San Francisco, California; Alabama College of Osteopathic Medicine, Dothan, Alabama
| | - Matthew Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gustavo J Sarria
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru; Department of Radiotherapy, AUNA Clinica Delgado, Lima, Peru
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18
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Stevens MJ, Ko F, Martland J, Brown R, Bell L, Atyeo J, Yim J. Safety and efficacy of single insertion accelerated MR-image guided brachytherapy following chemo-radiation in locally advanced cervix cancer: modifying our EMBRACE during the COVID pandemic. Radiat Oncol 2023; 18:54. [PMID: 36941643 PMCID: PMC10026240 DOI: 10.1186/s13014-023-02240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 03/06/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Utero-vaginal brachytherapy (BT) is an irreplaceable care component for the curative treatment of locally advanced cervix cancer (LACC). Magnetic Resonance Imaging (MRI)-image guided adaptive BT (IGABT) using the GYN-GEC-ESTRO EMBRACE guidelines is the international care standard. Usually following chemo-radiation therapy (CRT), IGABT has high proven utility in LACC but requires significant health system resources. Timely access was disrupted by the COVID-19 pandemic which challenged us to re-design our established IGABT care pathway. METHODS From April 2020 consecutive patients with LACC were enrolled after CRT in a single arm exploratory non-inferiority study of a modified IGABT (mIGABT) protocol. This delivered an iso-effective IGABT dose (39.3 Gy: EQD2: α/β10Gy concept) over a 24-h period during a single overnight hospitalisation. RESULTS Fourteen LACC patients received mIGABT from April 2020 to March 2022. Median age was 62.5 years (37-82 years). LACC histology was primary squamous (9/14) or adeno-carcinoma (5/14). International Federation of Gynaecology and Obstetrics (FIGO) 2018 stages ranged from IB1/2 (N = 3), IIA1/IIB (5), IIIB (2), IIIC1/2 (4) with mean ± standard deviation (SD) gross tumour volume-at-diagnosis (GTV_D) of 37.7 cc ± 71.6 cc. All patients achieved complete metabolic, clinical, and cytologic cancer response with CRT and IGABT. High-risk HPV was cleared by 6-months. Complete MRI-defined cancer response before mIGABT (GTV_Fx1) was seen in 77% of cases (10/13). Only two women developed metastatic disease and one died at 12-months; 13 patients were alive without cancer at mean 20.3 ± 7.2 months follow-up. Actuarial 2-year overall survival was 93%. Compared with our pre-COVID IGABT program, overall mIGABT cost-saving in this cohort was USD 22,866. Prescribed dose covered at least 90% (D90) of the entire cervix and any residual cancer at time of BT (HRCTV_D90: high-risk clinical target volume) with 3-fractions of 8.5 Gy delivered over 24-h (22.8 ± 1.7 h). Total treatment time including CRT was 38 days. The mIGABT schedule was well tolerated and the entire cohort met EMBRACE recommended (EQD2: α/β10Gy) combined HRCTV_D90 coverage of 87.5 ± 3.7 Gy. Similarly, organ-at-risk (OAR) median: interquartile range D2cc constraints (EQD2: α/β3Gy) were EMBRACE compliant: bladder (65.9 Gy: 58.4-72.5 Gy), rectum (59.1 Gy: 55.7-61.8 Gy), and sigmoid colon (54.6 Gy: 50.3-58.9 Gy). ICRU recto-vaginal point dose was significantly higher (75.7 Gy) in our only case of severe (G4) pelvic toxicity. CONCLUSIONS This study demonstrated the utility of mIGABT and VMAT CRT in a small cohort with LACC. Loco-regional control was achieved in all cases with minimal emergent toxicity. Single insertion mIGABT was logistically efficient, cost-saving, and patient-centric during the COVID-19 pandemic.
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Affiliation(s)
- Mark J Stevens
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia.
- Northern Clinical School, University of Sydney, St Leonards, NSW, Australia.
| | - Florence Ko
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia
| | - Judith Martland
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia
| | - Ryan Brown
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia
| | - Linda Bell
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia
| | - John Atyeo
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia
| | - Jackie Yim
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Level 1 ASB Building, St Leonards, NSW, 2065, Australia
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19
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Song S, Han D, Zhang N, Mao Z, Guo X, Cheng G. The MRI-guided two adaptive brachytherapy fractions versus one adaptive brachytherapy fraction in one application for the cervical cancer: a retrospective study. Radiat Oncol 2023; 18:46. [PMID: 36879287 PMCID: PMC9990264 DOI: 10.1186/s13014-023-02237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
PURPOSE This study retrospectively compared the clinical and toxicity outcomes for the cervical cancer of the MRI-guided two adaptive brachytherapy (IGABT) fractions versus one IGABT fraction in one application. METHODS One hundred and twenty patients with cervical cancer received external beam radiotherapy combined with or without concurrent chemotherapy, which was followed by the IGABT. The IGABT in 63 patients had one IGABT in each application (Arm 1), while in the other 57 patients, at least one treatment was two continuous IGABT every other day in one application (Arm 2). Clinical outcomes including overall survival (OS), cancer specific survival (CSS), progression free survival (PFS), local control (LC) were analyzed. Brachytherapy-related toxicities were evaluated, which included pain, dizziness, nausea/vomiting, fever/infection, blood loss during the removal of applicator and needles, the deep venous thrombosis, and other acute toxicities. The Common Terminology Criteria for Adverse Events (CTC-AE 5.0) was used to evaluate the incidence and severity of toxicities of the urinary system, lower digestive system, and reproduction system. Kaplan-Meier and the Log-rank test were used to analyze the clinical outcomes. RESULTS The median follow-up time of the patients in Arm 1 and Arm 2 was 23.5 and 12.0 months, respectively. The overall treatment time was significantly shorter in Arm 2 than Arm 1 (60 vs. 64 d; P = 0.017). The OS, CSS, PFS, and LC in Arm1 and Arm 2 was 77.8% vs. 86.0% (P = 0.632), 77.8% vs. 87.7% (P = 0.821), 68.3% vs. 70.2% (P = 0.207), and 92.1% vs. 94.7% (P = 0.583), respectively. The highest NRS of the pain during brachytherapy waiting period (2.22 ± 1.84 vs. 3.02 ± 1.65; P < 0.001) and at the time of the removal of the applicator (4.69 ± 1.49 vs. 5.30 ± 1.18; P < 0.001) in the patients who received one hybrid intracavitary and interstitial brachytherapy (IC/ISBT) in one application and two continuous IC/ISBT every other day in one application were significantly different. So far four patients with grade 3 late toxicities have been reported. CONCLUSIONS The findings of this study demonstrated that the two continuous IGABT every other day in one application is a logistically applicable, safe, and effective treatment strategy that could shorten the overall treatment time and reduce the medical cost, comparing with the one IGABT in one application.
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Affiliation(s)
- Shanshan Song
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Dongmei Han
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Ning Zhang
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Zhuang Mao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Xin Guo
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China.
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20
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Comparing dosimetry of locally advanced cervical cancer patients treated with 3 versus 4 fractions of MRI-guided brachytherapy. Brachytherapy 2023; 22:146-156. [PMID: 36528475 DOI: 10.1016/j.brachy.2022.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To demonstrate the feasibility of treating cervical cancer patients with MRI-guided brachytherapy (MRgBT) using 24 Gy in 3 fractions (F) versus a standard, more resource-intensive regimen of 28 Gy in 4F, and its ability to meet EMBRACE II planning aims. METHODS AND MATERIALS A retrospective review of 224 patients with FIGO Stage IB-IVA cervical cancer treated with 28 Gy/4F (n = 91) and 24 Gy/3F (n = 133) MRgBT between 2016-2021 was conducted. Multivariable linear regression models were fitted to compare dosimetric parameters between the two groups, adjusting for CTVHR and T stage. RESULTS Most patients had squamous cell carcinoma, T2b disease, and were treated with intracavitary applicator plus interstitial needles (96%). The 28 Gy/4F group had higher CTVHR (median 28 vs. 26 cm3, p = 0.04), CTVIR D98% (mean 65.5 vs. 64.5 Gy, p = 0.03), rectum D2cm3 (mean 61.7 vs. 59.2 Gy, p = 0.04) and bladder D2cm3 (81.3 vs. 77.9 Gy, p = 0.03). There were no significant differences in the proportion of patients meeting the EMBRACE II OAR dose constraints and planning aims, except fewer patients treated with 28 Gy/4F met rectum D2cm3 < 65 Gy (73 vs. 85%, p = 0.027) and ICRU rectovaginal point < 65 Gy (65 vs. 84%, p = 0.005). CONCLUSIONS Cervical cancer patients treated with 24 Gy/3F MRgBT had comparable target doses and lower OAR doses compared to those treated with 28 Gy/4F. A less-resource intense fractionation schedule of 24 Gy/3F is an alternative to 28 Gy/4F in cervix MRgBT.
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21
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Harkenrider MM, Abu-Rustum N, Albuquerque K, Bradfield L, Bradley K, Dolinar E, Doll CM, Elshaikh M, Frick MA, Gehrig PA, Han K, Hathout L, Jones E, Klopp A, Mourtada F, Suneja G, Wright AA, Yashar C, Erickson BA. Radiation Therapy for Endometrial Cancer: An American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol 2023; 13:41-65. [PMID: 36280107 DOI: 10.1016/j.prro.2022.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE With the results of several recently published clinical trials, this guideline informs on the use of adjuvant radiation therapy (RT) and systemic therapy in the treatment of endometrial cancer. Updated evidence-based recommendations provide indications for adjuvant RT and the associated techniques, the utilization and sequencing of adjuvant systemic therapies, and the effect of surgical staging techniques and molecular tumor profiling. METHODS The American Society for Radiation Oncology convened a multidisciplinary task force to address 6 key questions that focused on the adjuvant management of patients with endometrial cancer. The key questions emphasized the (1) indications for adjuvant RT, (2) RT techniques, target volumes, dose fractionation, and treatment planning aims, (3) indications for systemic therapy, (4) sequencing of systemic therapy with RT, (5) effect of lymph node assessment on utilization of adjuvant therapy, and (6) effect of molecular tumor profiling on utilization of adjuvant therapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation. RESULTS The task force recommends RT (either vaginal brachytherapy or external beam RT) be given based on the patient's clinical-pathologic risk factors to reduce risk of vaginal and/or pelvic recurrence. When external beam RT is delivered, intensity modulated RT with daily image guided RT is recommended to reduce acute and late toxicity. Chemotherapy is recommended for patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to II with high-risk histologies and those with FIGO stage III to IVA with any histology. When sequencing chemotherapy and RT, there is no prospective data to support an optimal sequence. Sentinel lymph node mapping is recommended over pelvic lymphadenectomy for surgical nodal staging. Data on sentinel lymph node pathologic ultrastaging status supports that patients with isolated tumor cells be treated as node negative and adjuvant therapy based on uterine risk factors and patients with micrometastases be treated as node positive. The available data on molecular characterization of endometrial cancer are compelling and should be increasingly considered when making recommendations for adjuvant therapy. CONCLUSIONS These recommendations guide evidence-based best clinical practices on the use of adjuvant therapy for endometrial cancer.
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois.
| | - Nadeem Abu-Rustum
- Department of Gynecologic Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Kristin Bradley
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | | | - Corinne M Doll
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Melissa A Frick
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Paola A Gehrig
- Division of Gynecologic Oncology, University of Virginia, Charlottesville, Virginia
| | - Kathy Han
- Department of Radiation Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Ellen Jones
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Ann Klopp
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas Mourtada
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California, San Diego, California
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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22
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Underutilization of brachytherapy for cervical cancer in the United States. Brachytherapy 2023; 22:15-20. [PMID: 36504160 DOI: 10.1016/j.brachy.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 12/13/2022]
Abstract
Brachytherapy is a critical component of the definitive management of cervical cancer and allows for the safe delivery of about half of the total effective radiation dose needed for optimal outcomes. Moreover, the dose distribution of brachytherapy is highly conformal, allowing for a therapeutic index currently unmatched by alternative techniques. However, a modern brachytherapy program requires special equipment, infrastructure, and procedural expertise. Unfortunately, multiple lines of evidence suggest that brachytherapy is currently underutilized in the United States. In this review, we examine the importance of brachytherapy, contemporary recommendations, and avenues for growth.
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23
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Vogel M, Gade J, Timm B, Schürmann M, Auerbach H, Nüsken F, Rübe C, Melchior P, Dzierma Y. Comparison of Breast Cancer Radiotherapy Techniques Regarding Secondary Cancer Risk and Normal Tissue Complication Probability - Modelling and Measurements Using a 3D-Printed Phantom. Front Oncol 2022; 12:892923. [PMID: 35965556 PMCID: PMC9365503 DOI: 10.3389/fonc.2022.892923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Radiotherapy after breast-conserving therapy is a standard postoperative treatment of breast cancer, which can be carried out with a variety of irradiation techniques. The treatment planning must take into consideration detrimental effects on the neighbouring organs at risk-the lung, the heart, and the contralateral breast, which can include both short- and long-term effects represented by the normal tissue complication probability and secondary cancer risk. Patients and Methods In this planning study, we investigate intensity-modulated (IMRT) and three-dimensional conformal (3D-CRT) radiotherapy techniques including sequential or simultaneously integrated boosts as well as interstitial multicatheter brachytherapy boost techniques of 38 patients with breast-conserving surgery retrospectively. We furthermore develop a 3D-printed breast phantom add-on to allow for catheter placement and to measure the out-of-field dose using thermoluminescent dosimeters placed inside an anthropomorphic phantom. Finally, we estimate normal tissue complication probabilities using the Lyman-Kutcher-Burman model and secondary cancer risks using the linear non-threshold model (out-of-field) and the model by Schneider et al. (in-field). Results The results depend on the combination of primary whole-breast irradiation and boost technique. The normal tissue complication probabilities for various endpoints are of the following order: 1%-2% (symptomatic pneumonitis, ipsilateral lung), 2%-3% (symptomatic pneumonitis, whole lung), and 1%-2% (radiation pneumonitis grade ≥ 2, whole lung). The additional relative risk of ischemic heart disease ranges from +25% to +35%. In-field secondary cancer risk of the ipsilateral lung in left-sided treatment is around 50 per 10,000 person-years for 20 years after exposure at age 55. Out-of-field estimation of secondary cancer risk results in approximately 5 per 10,000 person-years each for the contralateral lung and breast. Conclusions In general, 3D-CRT shows the best risk reduction in contrast to IMRT. Regarding the boost concepts, brachytherapy is the most effective method in order to minimise normal tissue complication probability and secondary cancer risk compared to teletherapy boost concepts. Hence, the 3D-CRT technique in combination with an interstitial multicatheter brachytherapy boost is most suitable in terms of risk avoidance for treating breast cancer with techniques including boost concepts.
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Affiliation(s)
- Marc Vogel
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Jonas Gade
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Bernd Timm
- Siemens Healthcare GmbH, Technical Service, Erlangen, Germany
| | - Michaela Schürmann
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Hendrik Auerbach
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Frank Nüsken
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Patrick Melchior
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Yvonne Dzierma
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
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24
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Chin C, Damast S. Radiation therapy in the definitive management of medically inoperable endometrial cancer. Int J Gynecol Cancer 2022; 32:323-331. [DOI: 10.1136/ijgc-2021-002532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/02/2021] [Indexed: 11/04/2022] Open
Abstract
The incidence of endometrial cancer continues to increase worldwide with growing life expectancy and rates of obesity. While endometrial cancer is primarily a surgical disease managed with hysterectomy, a small proportion of patients are deemed to be poor surgical candidates due to their co-morbidities. These medically inoperable patients should be considered for curative treatment with definitive radiation therapy, and brachytherapy is an integral component of their care. Referral to a high-volume center early on in the care of potentially inoperable patients is crucial to optimize their management. These patients should be evaluated by a high-risk surgical and anesthesia team to confirm their medical inoperability. For inoperable patients, use of image-guided brachytherapy is encouraged. Brachytherapy applicator selection is determined based on a patient’s anatomy, uterine size, and extent of tumor. Advances in anatomic and functional imaging including multiparametric magnetic resonance imaging (MRI) have improved clinical staging of these patients and have also allowed for the delivery of three-dimensional image-guided brachytherapy with improved accuracy. With recent consensus guidelines to guide local computed tomography and/or MRI volume-based delineation of targets and organs-at-risk, local outcomes have improved and treatments are delivered with less acute and late morbidity. Ongoing trials are looking at novel systemic agents, such as immunotherapy, to induce a systemic anti-tumor immune response and improve outcomes in these patients.
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25
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Huang L, Gaballa H, Chang J. Evaluating dosimetric accuracy of the 6 MV calibration on EBT3 film in the use of Ir-192 high dose rate brachytherapy. J Appl Clin Med Phys 2022; 23:e13571. [PMID: 35226398 PMCID: PMC9121041 DOI: 10.1002/acm2.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To evaluate the dosimetric accuracy of EBT3 film calibrated with a 6 MV beam for high dose rate brachytherapy and propose a novel method for direct film calibration with an Ir‐192 source. Methods The 6 MV calibration was performed in water on a linear accelerator (linac). The Ir‐192 calibration was accomplished by irradiating the film wrapped around a cylinder applicator with an Ir‐192 source. All films were scanned 1‐day post‐irradiation to acquire calibration curves for all three (red, blue, and green) channels. The Ir‐192 calibration films were also used for single‐dose comparison. Moreover, an independent test film under a H.A.M. applicator was irradiated and the 2D dose distribution was obtained separately for each calibration using the red channel data. Gamma analysis and point‐by‐point profile comparison were performed to evaluate the performance of both calibrations. The uncertainty budget for each calibration system was analyzed. Results The red channel had the best performance for both calibration systems in the single‐dose comparison. We found a significant 4.89% difference from the reference for doses <250 cGy using the 6 MV calibration, while the difference was only 0.87% for doses >600 cGy. Gamma analysis of the 2D dose distribution showed the Ir‐192 calibration had a higher passing rate of 91.9% for the 1 mm/2% criterion, compared to 83.5% for the 6 MV calibration. Most failing points were in the low‐dose region (<200 cGy). The point‐by‐point profile comparison reported a discrepancy of 2%–3.6% between the Ir‐192 and 6 MV calibrations in this low‐dose region. The linac‐ and Ir‐192‐based dosimetry systems had an uncertainty of 4.1% (k = 2) and 5.66% (k = 2), respectively. Conclusions Direct calibration of EBT3 films with an Ir‐192 source is feasible and reliable, while the dosimetric accuracy of 6 MV calibration depends on the dose range. The Ir‐192 calibration should be used when the measurement dose range is below 250 cGy.
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Affiliation(s)
- Lyu Huang
- Department of Radiation Medicine, Center for Advanced Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Hani Gaballa
- Department of Radiation Medicine, Center for Advanced Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Jenghwa Chang
- Department of Radiation Medicine, Center for Advanced Medicine, Northwell Health, New Hyde Park, New York, USA.,Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Department of Physics and Astronomy, Hofstra University, Hempstead, New York, USA
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26
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The role for vaginal cuff brachytherapy boost after external beam radiation therapy in endometrial cancer. Brachytherapy 2022; 21:177-185. [PMID: 35210017 DOI: 10.1016/j.brachy.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/10/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the role and technique of a vaginal cuff brachytherapy (VB) boost to adjuvant external beam (EB) radiation for endometrial cancer through a systematic review. METHODS AND MATERIALS Relevant trials were identified through a systematic search of the literature. RESULTS A total of 21 prospective and retrospective studies which had a patient cohort undergoing EB + VB was identified to evaluate for rates of vaginal and pelvic recurrences, overall survival, and toxicity. Additional database studies were utilized to demonstrate differences in local control and overall survival between EB and EB + VB. CONCLUSIONS While there is limited prospective evidence to guide the use of a VB boost after EB, the evidence suggests that patients with a higher risk of a vaginal recurrence such as those with cervical stromal involvement in select Stage III patients may derive local control and survival benefits from a VB boost. Additional individual risk factors such as grade, histology, extent of invasion, margin status, age, and the use of lower doses of EB should be considered when deciding when to add a VB boost.
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27
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Chow B, Warkentin B, Nanda K, Ghosh S, Huang F, Gamper AM, Menon G. BAIRDA: a novel in vitro setup to quantify radiobiological parameters for cervical cancer brachytherapy dose estimations. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac4fa3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/27/2022] [Indexed: 11/11/2022]
Abstract
Abstract
Objective. Brachytherapy (BT) dose prescriptions for locally advanced cervical cancer are made with account for the radiobiological parameters, α/β ratio and halftime of repair (T
1/2
). However, a wide range of parameter values has been reported which can challenge commonly held equivalencies between dose prescriptions. This is the first reported study that aims to develop an in vitro experimental technique using clinical high-dose-rate (HDR) and pulsed-dose-rate (PDR) Ir-192 brachytherapy afterloaders to quantify these parameters in vitro and to contextualize findings within contemporary practice. Approach. To efficiently quantify α/β and T
1/2
, in vitro experiments more reflective of clinical BT practice than traditional clonogenic survival assays were developed and applied to four squamous cell carcinoma cell lines (CaSki, C-33A, SiHa, and SW756). Radiation was delivered using single acute and fractionated dose treatments with a conventional irradiator and clinical HDR and PDR BT afterloaders. For the latter, a novel brachytherapy afterloader
in vitro
radiation delivery apparatus (BAIRDA) was developed. Main Results. The α/β and T
1/2
values determined using BAIRDA and the conventional irradiator showed close agreement, validating the novel apparatus and technique. For CaSki, C-33A, SiHa, and SW756, the BAIRDA-measured α/β ratios (5.2 [4.6–5.8], 5.6 [4.5–6.6], 6.3 [4.9–7.7], and 5.3 [4.7–6.0] Gy, respectively) were consistently smaller, while the T
1/2
(3.3 [2.7–3.9], 2.7 [2.0–3.3], 2.8 (2.4–3.1], and 4.8 [4.1–5.4] hours) larger, than the widely accepted values in clinical practice (α/β = 10 Gy; T
1/2
= 1.5 h). Significance. In vitro experiments using BAIRDA provided evidence for differences between the conventionally selected and experimentally determined α/β ratio and T
1/2
. Treatment regimens using HDR-BT and PDR-BT, designed to deliver equivalent radiobiological doses based on conventional values, were shown to differ by up to 27 Gy EQD2 – an effect that could impact treatment outcomes in cervical cancer. Furthermore, with BAIRDA, we have developed a novel method for radiobiological research in BT.
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Gangopadhyay A. Elimination of cervical cancer as a public health problem-how shorter brachytherapy could make a difference during COVID-19. Ecancermedicalscience 2022; 16:1352. [PMID: 35510136 PMCID: PMC9023303 DOI: 10.3332/ecancer.2022.1352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Indexed: 01/09/2023] Open
Abstract
The World Health Organization has called for elimination of cervical cancer as a public health problem and has adopted strategies in this regard. However, the estimates for achieving the goals depend on the ability to provide timely treatment in a certain proportion of cases. The coronavirus disease 2019 pandemic has had a serious impact on healthcare delivery in many low and middle income countries (LMICs) with the highest burden of cervical cancer; funds and infrastructure are being reallocated to deal with the emergency, and cancer care has been seriously affected. In the absence of clear and reliable estimates, the exact extent of disruption remains unclear. It is, therefore, essential that pragmatic approaches are adopted to save lives. There has been considerable debate regarding the use of the 9 Gy × 2 fractions high dose rate brachytherapy schedule for the treatment of locally advanced cervical carcinoma. However, in LMICs with the highest global burden of locally advanced cervical cancer cases, radiation facilities have been using this fractionation schedule in many cases to deal with the overwhelming number of patients, who would have otherwise been denied timely treatment. In view of the current pandemic, and the difficulties in accessing and delivering timely healthcare, mortality owing to delayed treatment cannot be denied in LMICs, which already have underequipped healthcare facilities. Use of the shortest available fractionation schedule to provide timely treatment would serve to save more lives in regions with high incidence and mortality from the disease.
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Ping Q, Zeng J, Sun P, Qu P, Jiang S, Hu Y. Efficacy of preoperative brachytherapy for controlling vaginal bleeding in early-stage cervical cancer: a retrospective study. Transl Cancer Res 2022; 10:3259-3267. [PMID: 35116632 PMCID: PMC8798223 DOI: 10.21037/tcr-21-467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Background In our clinical study, 11% of the patients with early-stage cervical cancers had different degrees of vaginal bleeding, which required a preoperative intervention. We set to assess the efficacy and safety of preoperative high-dose rate vaginal ovoid brachytherapy (HDR-VOBT) for the treatment of vaginal bleeding in women with early cervical cancer. Methods We retrospectively identified and reviewed patients with vaginal bleeding and early-stage cervical carcinoma, treated between January 2011 and December 2014 (median follow-up of 69 months). Of the 116 patients, 59 received preoperative HDR-VOBT (a dose of 8 Gy at 0.5 cm from the tumor surface), and 57 received traditional vaginal packing with gauze alone, followed by radical hysterectomy and lymphadenectomy. Analysis of the clinical parameters was performed using the chi-square test. The outcome measures were the 3- and 5-year survival and the complication rate. Results From the 116 patients, 25 had stage IB1, 49 had stage IB2, and 42 had stage IIA1 cervical cancer. No differences were observed regarding the 5-year overall survival (OS) (91.5% vs. 91.2%) and disease-free survival (DFS) (76.3% vs. 86%) between the preoperative HDR-VOBT group and the vaginal packing with gauze group. The mean volume of blood loss due to vaginal bleeding after treatment was 83.4 (range: 30–150) mL: 56.8 (range: 30–80) mL in the preoperative HDR-VOBT group and 111.1 (range: 80–150) mL in the gauze packing group (P<0.001). The mean time to achieve hemostasis was 3.5 h in the preoperative HDR-VOBT group and 8.1 h in the vaginal packing with gauze group (P<0.001). There was no significant difference in postoperative risk factors, complications, and survival between the two groups. Conclusions Preoperative HDR-VOBT with a dose of 8 Gy at 0.5 cm from the surface of the tumor has a better hemostatic effect than vaginal packing with gauze, with no additional complications and no need for adjuvant treatment after the operation.
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Affiliation(s)
- Quanhong Ping
- Department of Gynecologic Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Affiliated Hospital of Nankai University, Tianjin, China
| | - Jing Zeng
- Department of Gynecologic Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Affiliated Hospital of Nankai University, Tianjin, China
| | - Peisong Sun
- Department of Gynecologic Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Affiliated Hospital of Nankai University, Tianjin, China
| | - Pengpeng Qu
- Department of Gynecologic Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Affiliated Hospital of Nankai University, Tianjin, China
| | - Shan Jiang
- School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Yuanjing Hu
- Department of Gynecologic Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Affiliated Hospital of Nankai University, Tianjin, China
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le Guyader M, Lam Cham Kee D, Thamphya B, Schiappa R, Gautier M, Chand-Fouche ME, Hannoun-Levi JM. High-dose-rate brachytherapy boost for locally advanced cervical cancer: Oncological outcome and toxicity analysis of 4 fractionation schemes. Clin Transl Radiat Oncol 2022; 32:15-23. [PMID: 34816022 PMCID: PMC8592834 DOI: 10.1016/j.ctro.2021.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Brachytherapy (BT) boost after radio-chemotherapy (RCT) is a standard of care in the management of locally advanced cervical cancer (LACC). As there is no consensus on high-dose-rate (HDR) BT fractionation schemes, our aim was to report the oncological outcome and toxicity profile of four different schemes using twice-a-day (BID) HDR-BT. PATIENTS AND METHODS This was an observational, retrospective, single institution study for patients with LACC receiving a HDR-BT boost. The latter was performed with a single implant and single imaging done on day 1. The different fractionation schemes were: 7 Gy + 4x3.5 Gy (group 1); 7 Gy + 4x4.5 Gy (group 2); 3x7Gy (group 3) and 3x8Gy (group 4). Local (LFS), nodal (NFS) and metastatic (MFS) recurrence-free survival as well as progression-free survival (PFS) and overall survival (OS) were analyzed. Acute (≤6 months) and late toxicities (>6 months) were reported. RESULTS From 2007 to 2018, 191 patients were included. Median follow-up was 57 months [45-132] and median EQD210D90CTVHR was 84, 82 and 90 Gy for groups 2, 3 and 4 respectively (dosimetric data missing for group 1). The 5-year LFS, NFS, MFS, PFS and OS were 85% [81-90], 83% [79-86], 70% [67-73], 61% [57-64] and 75% [69-78] respectively, with no significant difference between the groups. EQD210D90CTVHR < 85 Gy was a prognostic factor for local recurrence in univariate analysis (p = 0.045). The rates of acute/late grade ≥ 2 urinary, digestive and gynecological toxicities were 9%/15%, 3%/15% and 9%/25% respectively. CONCLUSION Bi-fractionated HDR-BT boost seems feasible with good oncological outcome and slightly more toxicity after dose escalation.
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Key Words
- BED, biologically effective dose
- BID, twice-a-day
- BMI, body-mass index
- BT, brachytherapy
- Brachytherapy
- CT, computerized tomography
- CTCAE, common terminology criteria for adverse events
- CTV, clinical target volume
- Cervical cancer
- EBRT, external beam radiotherapy
- EMBRACE, image guided intensity modulated External beam radiochemotherapy and MRI based Adaptative BRAchytherapy in locally advanced CErvical cancer
- EQD2Gy, equivalent dose at 2 Gy
- ESTRO, European Society for Radiotherapy and Oncology
- FIGO, International Federation of Gynecology and Obstetrics
- Fractionation scheme
- GEC, groupe européen de curiethérapie
- GTV, gross tumor volume
- HDR, high-dose-rate
- HIV, human immunodeficiency virus
- HR, high-risk
- High-dose-rate
- ICRU, International Commission on Radiation Units and measurements
- IGABT, image-guided adaptative brachytherapy
- IMRT, intensity modulated radiotherapy
- IR, intermediate-risk
- LACC, locally advanced cervical cancer
- LDR, low-dose-rate
- LFS, local recurrence-free survival
- LQ, linear quadratic
- MFS, metastatic recurrence-free survival
- MFU, median follow up
- MRI, magnetic resonance imaging
- NA, not available
- NCI, national cancer institute
- NFS, nodal recurrence-free survival
- OAR, organs at risk
- OS, overall survival
- OTT, overall treatment time
- PDR, pulsed-dose-rate
- PET, positron emission tomography
- PFS, progression-free survival
- PTV, planning target volume
- RCT, radio-chemotherapy
- SCC, squamous cell cancer
- SEER, surveillance, epidemiology and end results
- pt, patient
- pts, patients
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Affiliation(s)
- Maud le Guyader
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Côte d’Azur, 33 avenue Valombrose, 06189 Nice Cedex 2, Nice, France
| | - Daniel Lam Cham Kee
- Department of Radiation Oncology, Pôle Santé République, Clermont-Ferrand, France
| | - Brice Thamphya
- Department of Statistics, Antoine Lacassagne Cancer Center, University of Côte d’Azur, Nice, France
| | - Renaud Schiappa
- Department of Statistics, Antoine Lacassagne Cancer Center, University of Côte d’Azur, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Côte d’Azur, 33 avenue Valombrose, 06189 Nice Cedex 2, Nice, France
| | - Marie-Eve Chand-Fouche
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Côte d’Azur, 33 avenue Valombrose, 06189 Nice Cedex 2, Nice, France
| | - Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Côte d’Azur, 33 avenue Valombrose, 06189 Nice Cedex 2, Nice, France
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Arden JD, Dokter J, Almahariq MF, Marvin K, Nandalur SR, Al-Wahab Z, Gadzinski J, Rosen B, Jawad MS. Toxicity and Efficacy After Adjuvant Vaginal Brachytherapy Using 30 Gy in 6 Fractions for Stages I and II Endometrial Cancer. Adv Radiat Oncol 2021; 6:100773. [PMID: 34934859 PMCID: PMC8655421 DOI: 10.1016/j.adro.2021.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose This study aimed to evaluate outcomes and toxicity in patients with endometrial cancer per our institutional adjuvant vaginal cuff brachytherapy (VBT) fractionation scheme. Methods and Materials We identified women with International Federation of Gynecology and Oncology stages I and II endometrial cancer who underwent surgical staging and adjuvant high-dose-rate VBT without external beam radiation. All patients received 30 Gy in 6 fractions to the upper one-third of the vagina, prescribed to a depth of 5 mm and delivered twice weekly. Toxicities were prospectively elicited at each follow up, and rates of recurrence and survival were retrospectively assessed. Results We identified 247 eligible patients treated between 1992 and 2018 with a median follow up of 5.8 years (range, 0.1-24.7 years). Most patients had stage I disease (52% stage IA; 37% stage IB), and 11% of patients were stage II. Deep myometrial invasion was predictive of local recurrence (P = .002). The 5-year rates of local recurrence, regional recurrence, and distant metastases were 5%, 5%, and 7%, respectively. Five-year overall and disease-free survival were 91% and 83%, respectively. The most common grade 1 toxicities were acute fatigue (11% crude rate), urinary frequency (11%), chronic (>6 months) urinary frequency (13%), urinary incontinence (13%), and vaginal stenosis (21%). There were few grade 2 toxicities (all <5%) and no grade 3 to 5 toxicities. Conclusions The adjuvant VBT fractionation scheme of 30 Gy in 6 fractions results in low rates of toxicity, with no grade ≥3 adverse events, and local control rates comparable with those from other published series using different fractionation schemes.
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Affiliation(s)
- Jessica D Arden
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jonathan Dokter
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kimberly Marvin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sirisha R Nandalur
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid Al-Wahab
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jill Gadzinski
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Barry Rosen
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Maha Saada Jawad
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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Gupta A, Dey T, Rai B, Oinam AS, Gy S, Ghoshal S. Point-Based Brachytherapy in Cervical Cancer With Limited Residual Disease: A Low- and Middle-Income Country Experience in the Era of Magnetic Resonance-Guided Adaptive Brachytherapy. JCO Glob Oncol 2021; 7:1602-1609. [PMID: 34843375 PMCID: PMC8624033 DOI: 10.1200/go.21.00147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the clinical outcomes in patients with cervical cancer with limited residual disease at brachytherapy (BT) treated with point-based dose prescription. METHODS Patients with locally advanced squamous cell carcinoma of the cervix treated with computed tomography (CT)-based intracavitary BT were considered for analysis. Patients with good response to external beam radiotherapy and limited residual disease suitable for intracavitary BT alone were included. Postapplication CT scans were performed before each fraction and individual plans were made for each session. The dose per fraction was 9Gy high dose rate, prescribed to point-A. Two sessions were planned, 1 week apart. The organs at risk were contoured, and cumulative dose-volume histograms were computed. Local control, pelvic control, disease-free survival, and overall survival were evaluated and late toxicities were documented. RESULTS Four hundred ninety patients were included. Overall, 79.8% had International Federation of Gynecology and Obstetrics (FIGO) stage IB2 to IIB disease and 20.2% had stage III to IVA disease. Median dose at point A (EQD210Gy) was 74.4 Gy (interquartile range [IQR] 72.3-74.5 Gy) and median D2cc (EQD23Gy) for bladder, rectum, and sigmoid were 82.5 Gy (IQR, 65.5-90.8 Gy), 66.5 Gy (IQR, 60.7-75.7 Gy), and 54.1 Gy (IQR, 50.5-77.3 Gy), respectively. At a median follow-up of 62 (IQR, 33-87) months, the 5-year local and pelvic control rates were 90.1% and 88.3%, respectively. The 5-year disease-free survival was 80% and overall survival was 88%. Rates of grade 3-4 bladder and rectosigmoid toxicities were 6.93% and 4.08%, respectively. CONCLUSION In patients with limited residual disease at BT, point-based dose prescription with CT planning results in good local control and acceptable toxicity. In a resource-constrained setting, patients may be triaged to receive point-based BT or magnetic resonance imaging–guided adaptive BT depending on the extent of residual disease. Point-based brachytherapy can be utilized in cervical cancer with limited residual disease after external RT
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Affiliation(s)
- Ankita Gupta
- Department of Radiotherapy, Regional Cancer Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Treshita Dey
- Department of Radiotherapy, Regional Cancer Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhavana Rai
- Department of Radiotherapy, Regional Cancer Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun S Oinam
- Department of Radiotherapy, Regional Cancer Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Srinivasa Gy
- Department of Radiotherapy, Regional Cancer Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sushmita Ghoshal
- Department of Radiotherapy, Regional Cancer Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Shah C, Vicini F, Beriwal S, Thaker N, Frank SJ, Rossi P, Orio P, Chang AJ, Joshi N, Campbell SR, Naghavi A, Chao S, Kamrava M, Deufel CL, Mourtada F, Suh JH. American brachytherapy society radiation oncology alternative payment model task force: Quality measures and metrics for brachytherapy. Brachytherapy 2021; 21:63-74. [PMID: 34732290 DOI: 10.1016/j.brachy.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/26/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Brachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience. RESULTS Key quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma. CONCLUSIONS This consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman cancer Center, Pittsburgh, PA
| | - Nikhil Thaker
- Division of Radiation Oncology, Arizona Oncology, Tucson, AZ
| | - Steven J Frank
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | | | - Peter Orio
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Albert J Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nikhil Joshi
- Department of Radiation Oncology, Rush University, Chicago, IL
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Arash Naghavi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Firas Mourtada
- Department of Radiation Oncology, Helen F. Graham Cancer Center, ChristianaCare, Newark, DE
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Dayyani M, Hoseinian-Azghadi E, Miri-Hakimabad H, Rafat-Motavalli L, Abdollahi S, Mohammadi N. Radiobiological comparison between Cobalt-60 and Iridium-192 high-dose-rate brachytherapy sources: Part I-cervical cancer. Med Phys 2021; 48:6213-6225. [PMID: 34415623 DOI: 10.1002/mp.15177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 05/26/2021] [Accepted: 07/30/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE This study aimed to compare the biological effective doses (BEDs) to clinical target volume (CTV) and organs at risk (OARs) for cervical cancer patients treated with high-dose-rate (HDR) Iridium-192 (192 Ir) or Cobalt-60 (60 Co) brachytherapy (BT) boost and to determine if the radiobiological differences between the two isotopes are clinically relevant. METHODS Considering all radiosensitivity parameters and their reported variations, the BEDs to CTV and OARs during HDR 60 Co/192 Ir BT boost were evaluated at the voxel level. The anatomical differences between individuals were also taken into account by retrospectively considering 25 cervical cancer patients. The intrafraction repair, proliferation, hypoxia-induced radiosensitivity heterogeneity, relative biological effectiveness (RBE), and source aging dose-rate variation were also taken into account. The comparisons in CTV were performed based on equivalent uniform BED (EUBED). RESULTS Considering nominal parameters with no RBE correction, the CTV EUBEDs were almost similar with a median ratio of ∼1.00 (p < 0.00001), whereas RBE correction resulted in 3.9%-5.5% (p = 0.005, median = 4.8%) decrease for 60 Co with respect to 192 Ir. For OARs, the median values of D2cc (in EQD23 ) for 60 Co were lower than that of 192 Ir up to 9.2% and 11.3% (p < 0.00001) for nominal parameters and fast repair conditions, respectively. In addition, for a nominal value (reported range) of radiosensitive parameters, the CTV EUBED differences of up to 6% (5%-10%) were assessed for HDR-BT component. CONCLUSION The RBE values are the most important cause of discrepancies between the two sources. By comparing BED/EUBEDs to CTV and OARs between 60 Co and 192 Ir sources, this numerical study suggests that a dose escalation to ∼4% is feasible and safe while sparing well the surrounding normal tissues. This 4% dose escalation should be benchmarked with clinical evidences (such as the results of clinical trials) before it can be used in clinical practice.
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Affiliation(s)
- Mahdieh Dayyani
- Radiation Oncology Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
| | | | - Hashem Miri-Hakimabad
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Laleh Rafat-Motavalli
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Sara Abdollahi
- Medical Physics Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
| | - Najmeh Mohammadi
- Physics Department, Faculty of Science, Sahand University of Technology, Tabriz, Iran
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Xue H, Qiu B, Wang H, Jiang P, Sukocheva O, Fan R, Xue L, Wang J. Stereotactic Ablative Brachytherapy: Recent Advances in Optimization of Radiobiological Cancer Therapy. Cancers (Basel) 2021; 13:cancers13143493. [PMID: 34298703 PMCID: PMC8304109 DOI: 10.3390/cancers13143493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 02/07/2023] Open
Abstract
Brachytherapy (BT), a type of focal anti-cancer radiotherapy, delivers a highly focused radiation dose to localized tumors, sparing surrounding normal tissues. Recent technological advances have helped to increase the accuracy of BT and, thus, improve BT-based cancer treatment. Stereotactic ablative brachytherapy (SABT) was designed to improve the ablative effect of radiation, which was achieved via improved image guidance, and calculation of ablative dose, shorter treatment duration, and better organ preservation. Recently collected data characterized SABT as having the potential to cure various early-stage cancers. The method provides higher tumor control rate levels that were previously achievable only by surgical resection. Notably, SABT is suitable for application with unresectable malignancies. However, the pathological assessment of SABT irradiated tumors is limited due to difficulties in specimen acquisition. Prostate, lung, liver, and gynecological cancers are the most commonly reported SABT-treated malignancies. This study will give an overview of SABT, focusing on the advances in SABT optimization, and provide insights on the future benefits of the combined application of SABT with cancer immunotherapies.
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Affiliation(s)
- Hui Xue
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Bin Qiu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Hao Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Olga Sukocheva
- Discipline of Health Sciences, College of Nursing and Health Sciences, Flinders University of South Australia, Bedford Park, SA 5042, Australia;
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China;
| | - Lixiang Xue
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
- Correspondence: (L.X.); (J.W.); Tel.: +86-13701076310 (L.X.); +86-13701076310 (J.W.)
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
- Correspondence: (L.X.); (J.W.); Tel.: +86-13701076310 (L.X.); +86-13701076310 (J.W.)
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Jensen GL, Barry PN, Eldredge-Hindy H, Silva SR, Todd SL, Hammonds KP, Zimmerman WR, Metzinger DS, El-Ghamry MN. Vaginal cuff brachytherapy: do we need to treat to more than a two-centimeter active length? J Contemp Brachytherapy 2021; 13:294-301. [PMID: 34122569 PMCID: PMC8170526 DOI: 10.5114/jcb.2021.105971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/09/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE American Brachytherapy Society (ABS) guidelines recommend using a 3-5 cm active length (AL) when treating vaginal cuff (VC) in adjuvant setting of endometrial cancer (EC). The purpose of this study was to evaluate local control and toxicity, using an AL of 1 or 2 cm and immobilization with a traditional table-mounted (stand) or patient-mounted (suspenders) device. MATERIAL AND METHODS Between 2005 and 2019, 247 patients with EC were treated with adjuvant high-dose-rate vaginal cuff (HDR-VC) brachytherapy with or without external beam radiation (EBRT). Treatment was prescribed to a 0.5 cm depth, with an AL of 1 or 2 cm, using stand or suspenders. VC boost after EBRT was typically administered with 2 fractions of 5.5 Gy, while VC brachytherapy alone was typically applied with 3 fractions of 7 Gy or 5 fractions of 5.5 Gy. RESULTS The combination of suspender immobilization and an AL of 2 cm (n = 126, 51%) resulted in 5-year local control of 100%. An AL of 2 cm compared to 1 cm correlated with better local control (99.1% vs. 88.5%, p = 0.0479). Regarding immobilization, suspenders correlated with improved local control compared to stand (100% vs. 86.7%, p = 0.0038). Immobilization technique was significantly correlated with AL (p < 0.0001). Only 5 (2.0%) patients experienced grade ≥ 3 toxicity, all of whom received EBRT. CONCLUSIONS In the present series, an AL of 2 cm provided excellent local control, while 1 cm was inadequate. Suspender immobilization was a practical alternative to stand immobilization in HDR brachytherapy of the vaginal cuff.
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Affiliation(s)
- Garrett L. Jensen
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
| | - Parul N. Barry
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women’s Hospital, Pittsburgh, USA
| | - Harriet Eldredge-Hindy
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Scott R. Silva
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Sarah L. Todd
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | | | - Walker R. Zimmerman
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
| | - Daniel S. Metzinger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Moataz N. El-Ghamry
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
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Ogorodniitchouk O, Aunier J, Bousarsar A, Lahmamssi C, Sotton S, Ouaz H, Moreno-Acosta P, Moslemi D, Molekzadehmoghani M, Langrand-Escure J, Magne N, Vallard A. Five-fraction HDR brachytherapy in locally advanced cervical cancer: A monocentric experience. Cancer Radiother 2021; 25:463-468. [PMID: 34023215 DOI: 10.1016/j.canrad.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/18/2021] [Accepted: 03/26/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The 5-fraction scheme (5×5-5.5Gy) is a common High-Dose Rate (HDR) intracavitary brachytherapy regimen for locally advanced cervical cancer (LACC). Yet, its equivalence with Pulse-Dose rate (PDR) schemes remains unproved. The present study aimed at reporting on the outcome of LACC patients treated with 5-fraction HDR brachytherapy. MATERIALS AND METHODS The medical records of all consecutive patients treated with curative-intent HDR brachytherapy for a LACC in a French Cancer Center were retrospectively reviewed. RESULTS Thirty-eight LACC patients underwent a 5-fraction intracavitary HDR brachytherapy between 2015 and 2019 (median dose=25Gy/5 fractions, following external-beam radiotherapy). Median age at diagnosis was 60 (range: 29-87). Thirty-one patients (81.5%) underwent concurrent chemotherapy. Tumor stages ranged from 3 IB2 (7.8%), 4 IB3 (10.5%), 4 IIA2 (10.5%), 12 IIB (31.7%), 1 IIIA (2.6%), 2 IIIB (5.3%), 7 IIIC1 (18.5%), 4 IIIC2 (10.5%), 1 IVA (2.6%) (2018 FIGO). Median D90% to CTVHR reached 79.5Gy (EQD2). Median D90% to CTVIR reached 59.5Gy (EQD2). Median Bladder D2cc was 69.8Gy (EQD2). Median Rectum D2cc was 58.3Gy (EQD2). Acute/late grade 3 toxicity was reported in one patient (2.6%). No grade 4-5 toxicity occurred. At a median 38 months follow-up, 10 patients (26.3%) had local (n=7, 18.4%), nodal (n=6, 15.7%) and/or distant (n=7, 18.4%) relapse. Three-year overall survival rate was of 81.6%. CONCLUSION The 5-fraction HDR scheme was well tolerated even in frail patients. Three-year local control was lower than expected. Treatment (absence of parametrial interstitial implants and use of cervical EBRT boost) and patients' characteristics (age, comorbidities) may explain such results.
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Affiliation(s)
- O Ogorodniitchouk
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - J Aunier
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - A Bousarsar
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - C Lahmamssi
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - S Sotton
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - H Ouaz
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - P Moreno-Acosta
- Research group in Cancer Biology, Research Branch, National Cancer Institute, Bogota, Colombia
| | - D Moslemi
- Departement of Clinical Radiotherapy & Oncology, Babol University of Medical Sciences, Babol, Iran
| | - M Molekzadehmoghani
- Department of Radiation-Oncology, Shahid Behesti University Medial Sciences, Tehran, Iran
| | - J Langrand-Escure
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
| | - N Magne
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France.
| | - A Vallard
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint-Priest en Jarez, France
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Facondo G, Vullo G, DE Sanctis V, Valeriani M, Ascolese AM, Massaro M, Anzellini D, Osti MF. Stereotactic Body Radiation Therapy Boost in Patients With Cervical Cancer Ineligible for Brachytherapy. CANCER DIAGNOSIS & PROGNOSIS 2021; 1:53-60. [PMID: 35403131 PMCID: PMC8962763 DOI: 10.21873/cdp.10008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 04/13/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Standard treatment for locally advanced cervical cancer is external beam radiotherapy followed by brachytherapy (BT). Stereotactic body radiation therapy (SBRT) is a possible option for treating patients ineligible for BT. PATIENTS AND METHODS From October 2012 to July 2020, nine women with cervical cancer received SBRT to high-risk volumes. The Kaplan-Meier method was used to estimate the rates of overall and disease-free survival. RESULTS The median age was 52 years; 88% of patients had squamous carcinoma. Reasons for forgoing BT were cervical canal stenosis, treatment refusal and hematological disease. The median boost dose was 18 Gy and the median dose per fraction was 6 Gy. Median follow-up was 16 months. The median survival was 24 months, the actuarial 2-year OS rate was 70%, and median disease-free survival was 11 months. One grade 3 late vaginal toxicity was reported. No acute nor late grade 4 toxicities were observed. CONCLUSION SBRT boost in patients with cervical cancer ineligible for BT led to acceptable survival outcomes and a safe toxicity profile.
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Affiliation(s)
- Giuseppe Facondo
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Gianluca Vullo
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Vitaliana DE Sanctis
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Maurizio Valeriani
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Anna Maria Ascolese
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Maria Massaro
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Dimitri Anzellini
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
| | - Mattia Falchetto Osti
- Department of Medicine and Surgery and Translational Medicine,Sapienza University of Rome, Radiotherapy Oncology, St. Andrea Hospital, Rome, Italy
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Adjuvant vaginal cuff brachytherapy in surgically treated endometrial carcinoma patients - in view of the recent evidence. J Contemp Brachytherapy 2021; 13:221-230. [PMID: 33897797 PMCID: PMC8060967 DOI: 10.5114/jcb.2021.105291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/01/2021] [Indexed: 12/24/2022] Open
Abstract
Vaginal cuff brachytherapy is an essential component of adjuvant post-operative therapy in endometrial carcinoma. Brachytherapy boost, as a part of adjuvant pelvic radiotherapy, including concomitant chemoradiotherapy combined with four cycles carboplatin/paclitaxel chemotherapy, is used in early-stage high-risk and advanced stage disease. This strategy is widely accepted and recommended by international guidelines, despite the fact that combined therapy has never been verified in randomized trials. Brachytherapy alone is the adjuvant treatment of choice for many patients with early-stage endometrial cancer, with high-intermediate features, replacing external beam pelvic radiotherapy. It provides equivalent vaginal control with a lower risk of toxicity, and minimal impact on health-related quality of life. Available evidence did not demonstrate the superiority of sole vaginal brachytherapy combined with three cycles of carboplatin/paclitaxel chemotherapy, over the standard pelvic irradiation for patients with early-stage, high-intermediate-, and high-risk endometrial cancer. This article summarized the available evidence on the role of post-operative vaginal cuff brachytherapy in endometrial cancer patients. Additionally, the risk groups definition, some aspects of brachytherapy technique, and the importance of pathological and molecular risk factors for endometrial cancer risk stratification were presented. Furthermore, the role of brachytherapy according to the European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology 2021 guidelines for the management of patients with endometrial carcinoma was presented.
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40
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Interstitial brachytherapy for gynecologic malignancies: Complications, toxicities, and management. Brachytherapy 2021; 20:995-1004. [PMID: 33789823 DOI: 10.1016/j.brachy.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022]
Abstract
From both a disease and management perspective, locally advanced gynecologic cancers present a significant challenge. Dose escalation with brachytherapy serves as a key treatment, providing conformal radiation while sparing at-risk organs. Intracavitary brachytherapy techniques have been shown to be effective, with improving tumor control and toxicity profiles with the advent of three-dimensional image planning. Despite this, the variations in tumor size, location, and pelvic anatomy may lead to suboptimal dosimetry with standard intracavitary applicators in some clinical scenarios. The addition of interstitial needles (interstitial brachytherapy (ISBT)) can improve the conformality of brachytherapy treatments by adding needles to peripheral (and central) regions of the target volume, improving the ability to escalate doses in these undercovered regions while sparing organs at risk. Interstitial brachytherapy can be delivered by intracavitary and interstitial hybrid applicators (ICBT/ISBT), perineal template (P-ISBT), or by free-hand technique. ISBT has however yet to be widely available because of concerns of complications and toxicities from this specialized treatment. However, with the increasing use of three-dimensional image-guided brachytherapy, there is an opportunity to increase the level of expertise in the gynecologic radiation oncology community with an improved understanding of the potential complications and morbidity. In this article, we review the acute and long-term toxicity in both ICBT/ISBT and P-ISBT using image-guided brachytherapy.
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Williams VM, Kahn JM, Thaker NG, Beriwal S, Nguyen PL, Arthur D, Petereit D, Dyer BA. The Case for Brachytherapy: Why It Deserves a Renaissance. Adv Radiat Oncol 2021; 6:100605. [PMID: 33723523 PMCID: PMC7940781 DOI: 10.1016/j.adro.2020.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/16/2020] [Accepted: 10/13/2020] [Indexed: 01/22/2023] Open
Abstract
The recent global events related to the coronavirus disease of 2019 pandemic have significantly changed the medical landscape and led to a shift in oncologic treatment perspectives. There is a renewed focus on preserving treatment outcomes while maintaining medical accessibility and decreasing medical resource utilization. Brachytherapy, which is a vital part of the treatment course of many cancers (particularly prostate and gynecologic cancers), has the ability to deliver hypofractionated radiation and thus shorten treatment time. Studies in the early 2000s demonstrated a decline in brachytherapy usage despite data showing equivalent or even superior treatment outcomes for brachytherapy in disease sites, such as the prostate and cervix. However, newer data suggest that this trend may be reversing. The renewed call for shorter radiation courses based on data showing equivalent outcomes will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.
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Affiliation(s)
- Vonetta M. Williams
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jenna M. Kahn
- Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon
| | - Nikhil G. Thaker
- Department of Radiation Oncology, Arizona Oncology, Tucson, Arizona
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Paul L. Nguyen
- Department of Radiation Oncology, Dana-Farber/Harvard Cancer Center, Boston, Massachusetts
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Petereit
- Department of Radiation Oncology, Monument Health Cancer Care Institute, Rapid City, South Dakota
| | - Brandon A. Dyer
- Department of Radiation Oncology, University of Washington, Seattle, Washington
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High-dose-rate interstitial brachytherapy with hypoxic radiosensitizer KORTUC II for unresectable pelvic sidewall recurrence of uterine cervical cancer: a case report. J Contemp Brachytherapy 2021; 12:606-611. [PMID: 33437310 PMCID: PMC7787211 DOI: 10.5114/jcb.2020.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/16/2020] [Indexed: 11/25/2022] Open
Abstract
In order to improve oncologic outcomes in radiotherapy treatments of patients with unresectable pelvic sidewall recurrences of uterine cervical cancer, we combined high-dose-rate interstitial brachytherapy (HDR-ISBT) with newly tested hypoxic radiosensitizer Kochi oxydol-radiation therapy for unresectable carcinomas (KORTUC II), an enzyme-targeting radiosensitization treatment involving intra-tumoral injection of sodium hyaluronate mixed with hydrogen peroxide. We report on a 63-year-old patient referred to our department with an extensive pelvic sidewall recurrence of uterine cervical cancer after initial hysterectomy. The tumor size was 55 × 25 × 80 mm, with a calculated volume of 89.7 cc. Whole pelvic irradiation of 50 Gy in 25 fractions was administered, combined with weekly cisplatin injections. KORTUC II injections were given two times: at day 21 (42 Gy) and at day 24 (48 Gy). After finishing whole pelvic irradiation, HDR-ISBT of 25 Gy in 5 fractions b.i.d. over 3 days was administered. KORTUC II was also injected at the time of implantation. Dose-volume histogram (DVH) values for clinical target volume were D90, D98, and D100 of 6.0, 5.0, and 3.5 Gy per fraction, respectively. D2cc values were 2.1, 4.1, 3.2, and 2.0 Gy per fraction for the bladder, rectum, sigmoid colon, and small bowel, respectively. No acute adverse events ≥ grade 3 were observed. Repeated grade 3 pyelonephritis occurred as a late complication at 11, 24, and 26 months after the treatment, and was successfully resolved with antibiotics. Moreover, grade 2 late toxicity was documented, including sciatic neuralgia, lower limb lymphedema, and urinary incontinence. At present, 32 months after HDR-ISBT, the patient remains free of disease, with no toxicity-related deterioration in physical condition.
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Dewan A, Mitra S, Aggarwal S, Barik S, Kaur I, Umesh P, Dewan R. Management of cervical cancer during the corona virus disease-19 (COVID-19) era. Br J Radiol 2020; 94:20200686. [PMID: 33216637 PMCID: PMC7774674 DOI: 10.1259/bjr.20200686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
COVID-19 pandemic has had a catastrophic impact on the society, economy and heath-care system all over the globe with virus showing no signs of losing potency. As the situation appears to worsen, extra burden on other specialities like oncology seems to increase. Specific recommendations are necessary for management of cervical cancer in the current context. All concerned specialities must work together in the best interest of the patient. Attempts should be made at managing cervical cancer while limiting the viral spread among the patients and health-care workers without the loss of opportunity. Surgical intervention for early cervical cancer should be postponed or alternative modalities be considered. In a locally advanced disease, concurrent chemoradiation is the treatment of choice. In addition, the following under mentioned suggestions aim to discuss ways of minimizing infection spread, workload rationalization and providing guidance for management of cervical cancer in the presence of COVID-19 infection.
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Affiliation(s)
- Abhinav Dewan
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Swarupa Mitra
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Sumeet Aggarwal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Soumitra Barik
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Inderjeet Kaur
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Preetha Umesh
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Rupali Dewan
- Department of Gynecology and Obstetrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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44
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Kumar D, Dey T. Recapitulating intracavitary brachytherapy in cervical cancer patients during the COVID-19 pandemic: a viewpoint. Future Oncol 2020; 16:2143-2146. [PMID: 32776790 PMCID: PMC7422724 DOI: 10.2217/fon-2020-0588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Divyesh Kumar
- Department of Radiotherapy & Oncology, PGIMER, Chandigarh 160012, India
| | - Treshita Dey
- Department of Radiotherapy & Oncology, PGIMER, Chandigarh 160012, India
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Elledge CR, Beriwal S, Chargari C, Chopra S, Erickson BA, Gaffney DK, Jhingran A, Klopp AH, Small W, Yashar CM, Viswanathan AN. Radiation therapy for gynecologic malignancies during the COVID-19 pandemic: International expert consensus recommendations. Gynecol Oncol 2020; 158:244-253. [PMID: 32563593 PMCID: PMC7294297 DOI: 10.1016/j.ygyno.2020.06.486] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/10/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic. METHODS An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel. RESULTS Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended. CONCLUSIONS The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19.
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Affiliation(s)
- Christen R Elledge
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, PA, USA
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Small
- Department of Radiation Oncology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Catheryn M Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, CA, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Williams VM, Kahn JM, Harkenrider MM, Chino J, Chen J, Fang LC, Dunn EF, Fields E, Mayadev JS, Rengan R, Petereit D, Dyer BA. COVID-19 impact on timing of brachytherapy treatment and strategies for risk mitigation. Brachytherapy 2020; 19:401-411. [PMID: 32359937 PMCID: PMC7172676 DOI: 10.1016/j.brachy.2020.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/10/2020] [Accepted: 04/10/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to highlight the importance of timely brachytherapy treatment for patients with gynecologic, breast, and prostate malignancies, and provide a framework for brachytherapy clinical practice and management in response to the COVID-19 pandemic. METHODS AND MATERIALS We review amassing evidence to help guide the management and timing of brachytherapy for gynecologic, breast, and prostate cancers. Where concrete data could not be found, peer-reviewed expert opinion is provided. RESULTS There may be a significant negative impact on oncologic outcomes for patients with gynecologic malignancies who have a delay in the timely completion of therapy. Delay of prostate or breast cancer treatment may also impact oncologic outcomes. If a treatment delay is expected, endocrine therapy may be an appropriate temporizing measure before delivery of radiation therapy. The use of shorter brachytherapy fractionation schedules will help minimize patient exposure and conserve resources. CONCLUSIONS Brachytherapy remains a critical treatment for patients and may shorten treatment time and exposure for some. Reduced patient exposure and resource utilization is important during COVID-19. Every effort should be made to ensure timely brachytherapy delivery for patients with gynecologic malignancies, and endocrine therapy may help temporize treatment delays for breast and prostate cancer patients. Physicians should continue to follow developing institutional, state, and federal guidelines/recommendations as challenges in delivering care during COVID-19 will continue to evolve.
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Affiliation(s)
| | - Jenna M Kahn
- Department of Radiation Oncology, Oregon Health & Science University, Portland, OR
| | | | - Junzo Chino
- Department of Radiation Oncology, Duke University, Durham, VA
| | - Jonathan Chen
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - L Christine Fang
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Emily F Dunn
- Department of Radiation Oncology, Willamette Valley Cancer Institute and Research Center, Eugene, OR
| | - Emma Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Jyoti S Mayadev
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Daniel Petereit
- Department of Radiation Oncology, Monument Health Cancer Care Institute, Rapid City, SD
| | - Brandon A Dyer
- Department of Radiation Oncology, University of Washington, Seattle, WA.
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47
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Brachytherapy in cervical cancer radiotherapy during COVID-19 pandemic crisis: problems and prospects. J Contemp Brachytherapy 2020; 12:290-293. [PMID: 32695203 PMCID: PMC7366013 DOI: 10.5114/jcb.2020.96873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/23/2020] [Indexed: 01/12/2023] Open
Abstract
COVID-19 pandemic has adversely affected general healthcare delivery systems and cancer care throughout the world. The management of locally advanced cervical cancer presents specific challenges in this context, especially brachytherapy and completion of radiotherapy treatment, without compromising the overall treatment time and anticipated outcomes. This article presents in detail the issues and possible solutions with currently available literature for COVID-19 and radiation, in particular brachytherapy management of locally advanced cervical cancers. The review attempts to provide possible explanations and pathways based on COVID-19 testing, brachytherapy processes including application, imaging, and fractionation, keeping in mind the overall treatment time.
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48
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Aghili M, Jafari F, Vand Rajabpoor M. Brachytherapy during the coronavirus disease 2019 - Lessons from Iran. Brachytherapy 2020; 19:412-414. [PMID: 32410912 PMCID: PMC7221400 DOI: 10.1016/j.brachy.2020.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE COVID-19 outbreak is not a short-time crisis, and discontinuing or postponing life-saving treatments is not logical. Brachytherapy is one of the important treatment modalities for some subsites of cancers. Therefore, we decided to consider some of the best feasible brachytherapy regimes during the pandemic. METHODS AND MATERIALS We considered brachytherapy guidelines and landmark trials and selected the most efficacious indications of brachytherapy, considering the best regimens to minimize the risk of exposure to the novel coronavirus. RESULTS We developed appropriate recommendations amid the COVID-19 pandemic for brachytherapy management of cervical, endometrial, breast, prostate, head and neck, and soft-tissue sarcomas. CONCLUSIONS Brachytherapy provides an opportunity for the patients and the physicians during the COVID-19 outbreak; it can retain the patient's chance for treatment while limiting the chance of exposure and transmission of infection.
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Affiliation(s)
- Mahdi Aghili
- Radiation Oncology Research Center, Iran Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran; Yas Radiation Oncology Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Jafari
- Radiation Oncology Research Center, Iran Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mojtaba Vand Rajabpoor
- Cancer Research Center, Iran Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
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Mohindra P, Beriwal S, Kamrava M. Proposed brachytherapy recommendations (practical implementation, indications, and dose fractionation) during COVID-19 pandemic. Brachytherapy 2020; 19:390-400. [PMID: 32423787 PMCID: PMC7252026 DOI: 10.1016/j.brachy.2020.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, CA.
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One-week vaginal brachytherapy schedule as exclusive adjuvant post-operative treatment in intermediate- and high-intermediate-risk endometrial cancer patients. J Contemp Brachytherapy 2020; 12:124-130. [PMID: 32395136 PMCID: PMC7207237 DOI: 10.5114/jcb.2020.94581] [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: 09/16/2019] [Accepted: 12/14/2019] [Indexed: 01/20/2023] Open
Abstract
Purpose The aim of the study was to report survival outcomes and toxicities incidence by using one-week vaginal brachytherapy (VBT) schedule in intermediate- and high-intermediate-risk endometrial cancer patients. Material and methods One hundred and eight patients were treated with exclusive high-dose-rate (HDR) brachytherapy short schedule (7 Gy/fraction/every other day/1 week). Acute and late rectal, urinary, and vaginal toxicities were recorded according to radiation therapy oncology group (RTOG) scores and late effects normal tissue task force – subjective, objective, management, analytic (LENT-SOMA) scores, respectively. Overall survival (OS), cause specific survival (CSS), and disease-free survival (DFS) were evaluated. Results Median follow-up was 44 months (range, 6-117 months). The 5-year OS, CSS, and DFS rates were 92.7%, 96.4%, and 89.5%, respectively. Seven of 108 (6.5%) patients relapsed after a median time of 31 months (range, 5-56 months). Death occurred in 6 patients. Four patients died for intercurrent causes without an evidence of disease. Acute bladder toxicity G1-G2 was reported in 11 of 108 (10%) patients, vaginal toxicity G1-G2 in 6 of 108 (5.5%), and gastrointestinal toxicity was observed in 3 of 108 (3%) patients. Late bladder and gastrointestinal G1 toxicities were reported in 4 of 108 (4%) and 1 of 108 (1%) patients, respectively. Late vaginal toxicity (G1-G2) was recorded in 3 of 108 (3%) cases. No grade 3-4 bladder, vaginal, and gastrointestinal toxicities were noted. Conclusions Exclusive short course adjuvant VBT is an effective treatment in patients with early-stage endometrial cancer and provides good outcomes in terms of disease local control and DFS, with low rates of toxicity profile.
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