Conformal and intensity-modulated radiotherapy for cervical cancer. Clin Oncol (R Coll Radiol). 2008;20:417-425. [PMID: 18558480 DOI: 10.1016/j.clon.2008.04.004]

Feasibility of using a dual isocentre technique for treating cervical cancer on the 1.5 T MR-Linac

Objective.Patients treated for cervical cancer exhibit large inter and intra-fraction anatomical changes. The Unity MR-Linac (MRL) can image these patients with MR prior to and during treatment which enables daily plan adaptation. However, the MRL has a limited treatment field in the sup/inf direction of 22 cm which can restrict the treatment of patients who require longer treatment fields. Here we explore potential adaptive workflows in combination with a dual isocentre approach, to widen the range of cervix patients that can benefit from this treatment.Approach.Ten cervical cancer patients were retrospectively planned with a dual isocentre technique to deliver 45 Gy in 25 fractions. 5 node-negative and 5 node-positive patients were planned using the EMBRACE II protocol. A 2 cm overlap region between the two isocentres was positioned entirely in the nodal region. A treatment workflow was simulated to account for inter-fraction anatomical change. Isocentre shifts of 3 and 6 mm were applied to investigate the effect of intra-fraction motion.Main results.Dual isocentre adapted plans ensured significantly better coverage than non-adapted (recalculated) plans with a larger benefit seen for the node-negative cases. The difference to the reference plan for the V4275 cGy to the ITV was -0.8 cGy and -8.2 cGy for the adapted and recalculated plans respectively. Movements superiorly did not affect the coverage of the ITV by more than 1%, but shifting it inferiorly caused the ITV coverage on the plan to reduce by ∼2.4% per mm.Significance.A dual isocentre technique for cervical cancer treatments and adaptive workflows have been demonstrated to recover the required plan quality for inter-fraction changes. This illustrates the feasibility of a dual isocentre technique for the MRL.

Significant impact on the oncologic outcomes with intensity modulated radiotherapy and conformational radiotherapy over conventional radiotherapy in cervix cancer patients treated with radiotherapy

OBJECTIVE

We designed a retrospective cohort of women with cervix cancer treated by radiation therapy with an extended follow-up to evaluate if the incorporation of modern radiation techniques was a prognostic factor.

MATERIAL AND METHODS

We studied a cohort of patients with cervix cancer FIGO stage I-IVa treated in the last fifteen years. Patients were treated with radiotherapy alone (RT) or chemoradiation alone (CRT) using conventional radiotherapy (2DRT), conformational radiotherapy (3DRT), or intensity-modulated radiotherapy (IMRT) followed by high dose rate brachytherapy. Univariate and multivariate analysis was conducted to identify significant prognostic factors (p < 0.05).

RESULTS

228 patients with cervix cancer were included. The treatment groups were CRT (64.8%), and RT (34.2%), with 31.6% submitted to 2DRT and 68.4% to IMRT/3DRT. The median follow-up was 6.3 years, the OS in 5 years according to the treatment groups was 48% for CRT, and 27.8% for RT (p < 0.001). The early-stage I-IIa (p = 0.001), CRT, and IMRT/3DRT were significant factors for better overall survival (OS) in the multivariate analysis. For the cancer-specific survival (CSS), chemoradiation, age <60 years, and IMRT/3DRT were significant. Treatment with IMRT/3DRT was the only prognostic factor associated with event-free survival (EFS).

CONCLUSION

In a long-term follow-up, chemoradiation, early-clinical stage, and age <60 years were significant factors associated with better OS and CSS at 5 and 8 years. The incorporation of new radiation techniques, such as IMRT/3DRT, over time has a significant impact on all endpoints (EFS, OS, and CSS) of this cohort. These outcomes are useful to decide about the radiation technique to achieve satisfactory oncological results outside a clinical trial.

Increased High-Risk Human Papillomavirus Viral Load Is Associated With Immunosuppressed Microenvironment and Predicts a Worse Long-Term Survival in Cervical Cancer Patients

OBJECTIVES

To evaluate the correlation between tumor-infiltrating lymphocytes (TILs) and the viral load of high-risk human papillomavirus (HR-HPV) in cervical cancer patients.

METHODS

A total of 62 cervical cancer patients were recruited during 1993-1994 and assigned into four groups treated with radiotherapy alone or radiotherapy combined with chemotherapy and/or thermotherapy. Ki67+ tumor cells, CD4+, CD8+, FoxP3+, OX40+ and granzyme B+ TILs were detected by immunohistochemistry. The viral load of HR-HPV in biopsy tissues before therapy was detected by in situ hybridization.

RESULTS

The patients with high HPV viral load showed a significantly lower 15-year survival rate and an advanced International Federation of Gynecology and Obstetrics (FIGO) stage and increased recurrence rate. The distribution of Ki67+ tumor cells, FoxP3+ TILs, and CD8+/FoxP3+ ratio was obviously different between low and high HPV viral load groups. A worse clinical outcome was also implicated with increased HPV viral load tested by Cox regression analysis.

CONCLUSIONS

Patients with increased HR-HPV viral load tend to be resistant to therapy with decreased immune surveillance in the immune microenvironment. Thus, HR-HPV viral load would influence the local immune microenvironment, and then further affect the survival of cervical cancer patients.

Postoperative pelvic intensity-modulated radiation therapy reduced the incidence of late gastrointestinal complications for uterine cervical cancer patients

The aim of the study was to compare incidences of late gastrointestinal adverse events and clinical outcomes between 3D conformal radiation therapy (3DCRT) and intensity-modulated radiation therapy (IMRT) after radical hysterectomy for cervical cancer patients. Between March 2007 and May 2014, 73 cervical cancer patients with high-risk prognostic factors (pelvic lymph node metastasis and/or parametrial invasion) underwent postoperative pelvic radiation therapy (RT) after radical hysterectomy. Of these patients, 33 (45%) and 40 (55%) received 3DCRT and IMRT, respectively. Because the gastrointestinal obstruction rate after postoperative pelvic 3DCRT was high, no concurrent chemotherapy was applied until 2015. The median follow-up period for patients with 3DCRT and IMRT was 82 months (6-113) and 50 months (5-74), respectively. There was no significant difference in overall survival (OS) (4-year OS: 85% vs 78%, P = 0.744) or disease-free survival (DFS) (4-year DFS: 73% vs 64%, P = 0.696) between the two groups. Eleven (33%) and 13 (33%) patients experienced recurrence after 3DCRT and IMRT, respectively. The patients who had vaginal invasion from the postoperative pathological finding more frequently had loco-regional recurrence than the patients who did not have vaginal invasion (2.3% vs 17%, P = 0.033). Gastrointestinal obstruction was observed in 9 (27%) and 3 (7.5%) patients for 3DCRT and for IMRT, respectively (P = 0.026). Severe gastrointestinal obstruction that required surgery was observed in 6 (19%) patients, all of whom received adjuvant RT by 3DCRT. IMRT could reduce the incidence of late severe gastrointestinal obstruction after postoperative pelvic RT with a non-inferior clinical efficacy compared with 3DCRT.

The Potential Value of MRI in External-Beam Radiotherapy for Cervical Cancer

The reference standard treatment for cervical cancer is concurrent chemoradiotherapy followed by magnetic resonance imaging (MRI)-guided brachytherapy. Improvements in brachytherapy have increased local control rates, but late toxicity remains high with rates of 11% grade ≥3. The primary clinical target volume (CTV) for external-beam radiotherapy includes the cervix and uterus, which can show significant inter-fraction motion. This means that generous margins are required to cover the primary CTV, increasing the radiation dose to organs at risk and, therefore, toxicity. A number of image-guided radiotherapy techniques (IGRT) have been developed, but motion can be random and difficult to predict prior to treatment. In light of the development of integrated MRI linear accelerators, this review discusses the potential value of MRI in external-beam radiotherapy. Current solutions for managing pelvic organ motion are reviewed, including the potential for online adaptive radiotherapy. The impacts of the use of MRI in tumour delineation and in the delivery of stereotactic ablative body radiotherapy (SABR) are highlighted. The potential role and challenges of using multi parametric MRI to guide radiotherapy are also discussed.

Comparison of dosimetric parameters and acute toxicity of intensity-modulated and three-dimensional radiotherapy in patients with cervix carcinoma: A randomized prospective study

PURPOSE

The use of intensity-modulated radiotherapy (IMRT) to treat cervix carcinoma has increased, however prospective randomized trials are still lacking.

AIM

To compare the dosimetric parameters and associated acute toxicity in patients with cervix carcinoma treated with three-dimensional (3D) conformal radiotherapy and IMRT.

PATIENTS AND METHODS

Forty patients were randomized in two arms each consisting of 20 patients. Patients in both arms received concurrent chemoradiation (cisplatin 40mg/m(2) weekly; 50Gy/25 fractions). Patients were treated with 3D conformal radiotherapy in one arm and with IMRT in another arm. After external beam radiotherapy, all patients received brachytherapy (21Gy/3 fractions at weekly interval). For dosimetric comparison, both kinds of the plans were done for all the patients. All patients were assessed throughout and until 90 days after completion of treatment for acute gastrointestinal, genitourinary and hematologic toxicities.

RESULTS

Both plans achieved adequate planning target volume coverage, while mean conformity index was found significantly better in IMRT plans (P-value=0.001). D35 (dose to 35% volume) and D50 for bladder was reduced by 14.62 and 32.57% and for rectum by 23.82 and 43.68% in IMRT. For IMRT, V45 (volume receiving 45Gy) of bowel were found significantly lesser (P-value=0.0001), non-tumour integral dose was found significantly higher (P-value=0.0240) and V20 of bone marrow was found significantly reduced (P-value=0.019) in comparison to that in 3D conformal radiotherapy. Significant reduction of grade 2 or more (20 vs 45%; P-value=0.058) and grade≥3 (5 vs 15%, P-value=0.004) acute genitourinary toxicity and grade 2 or more (20 vs 45%, P-value=0.003) and grade 3 or more (5 vs. 20%, P-value=0.004) acute gastrointestinal toxicity while no significant difference for grade 2 and 3 or more haematological toxicity was noted in patients treated with IMRT compared to 3D conformal radiotherapy.

CONCLUSION

IMRT provide a good alternative for treatment of cervix carcinoma with lower acute gastrointestinal and acute genitourinary toxicity with similar target coverage compared to 3D conformal radiotherapy.

Treatment of Older Women With Endometrial Cancer: Improving Outcomes With Personalized Care

Endometrial cancer is the most common gynecologic cancer, and with a median age of 62 at diagnosis, it affects a significant number of older women. With increasing age and obesity rates in the world's population, there is an anticipated concomitant increase in older women with endometrial cancer. Older women are more likely to die of endometrial cancer compared with younger patients. Reasons for this include more aggressive tumor biology, less favorable clinicopathologic features, and more advanced disease. Other factors, however, such as reluctance to offer surgical treatment to the older patient and increased complications of treatment are likely to be important. Management of endometrial cancer requires multidisciplinary care (surgery, radiation therapy, and systemic therapy). For each treatment, the feasibility (related to technical aspect of the procedure/treatment), side effects and safety (related to older-patient factors), and the overall benefit as it pertains to older women with endometrial cancer should be assessed carefully with a multidisciplinary approach. Despite the importance of these issues, the data are limited to answer these issues with clarity. In this article, we will review each treatment modality for older women with endometrial cancer. We will introduce the components of comprehensive geriatric assessment and their practical implication for older women with cancer in general and older women with endometrial cancer specifically.

Distribution pattern of lymph node metastases and its implication in individualized radiotherapeutic clinical target volume delineation of regional lymph nodes in patients with stage IA to IIA cervical cancer

BACKGROUND

To study the distribution pattern of lymph node metastases of stage IA to IIA cervical cancer and to clarify the individualized clinical target volume delineation of regional lymph nodes (CTVn).

METHODS

A total of 665 cases with International Federation Gynecology and Obstetrics stage IA to IIA cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy were retrospectively reviewed. The clinicopathological factors related to lymph node metastases were analyzed using logistic regression analysis.

RESULTS

Pelvic lymph node metastases were found in 168 of 665 patients resulting in a metastasis rate of 25.3%. Binary logistic regression analysis showed that age, lymph vascular space involvement, and deep stromal invasion statistically influenced pelvic lymph node metastases (p = 0.017, < 0.001, < 0.001, respectively). Pathological morphology type, lymph node metastases of the obturator, the external iliac and internal iliac, and the para-aortic had a strong influence on lymph node metastases of the common iliac (p = 0.022, 0.003, < 0.001, 0.009, respectively). Tumor size and lymph node metastases of the common iliac were significantly related to lymph node metastases of the para-aortic (p = 0.045, < 0.001, respectively). Lymph node metastases of the obturator, the external iliac and internal iliac were strongly correlated to lymph node metastases of the circumflex iliac node distal to the external iliac node (CINDEIN; p = 0.027, 0.024, respectively).

CONCLUSIONS

Factors related to lymph node metastases should be comprehensively considered to design and tailor CTVn for radiotherapy of cervical cancer. Selective regional irradiation including the correlated lymphatic drainage regions should be performed.

Impact of pelvic radiotherapy on the female genital tract and fertility preservation measures

Radiotherapy to the pelvis can have a major and deleterious impact on the female genital tract. Despite significant advances in the technical delivery of radical pelvic radiotherapy there remains no way to avoid delivering substantial radiation doses to the ovaries and uterus for patients undergoing treatment for gynaecological cancers. Due to improved cure rates from radical chemo-radiotherapy and social trends toward delayed childbirth many women treated for cervical cancer with radical chemo-radiotherapy will wish to attempt to preserve their fertility. Whilst there are now established and emerging techniques for preserving ovarian function and ovarian tissue, there remains the difficulty of the irradiated uterus which, even if pregnancy can be achieved, results in an increased risk for pregnancy-related complications. Future developments may offer women in this difficult situation more and improved options for fertility preservation.

Dosimetric comparison of different multileaf collimator leaves in treatment planning of intensity-modulated radiotherapy for cervical cancer

To study the effect of multileaf collimator (MLC) leaf widths (standard MLC [sMLC] width of 10mm and micro-MLC [mMLC] width of 4mm) on intensity-modulated radiotherapy (IMRT) for cervical cancer. Between January 2010 and August 2010, a retrospective analysis was conducted on 12 patients with cervical cancer. The treatment plans for all patients were generated with the same machine setup parameters and optimization methods in a treatment planning system (TPS) based on 2 commercial Elekta MLC devices. The dose distribution for the planning tumor volume (PTV), the dose sparing for organs at risk (OARs), the monitor units (MUs), and the number of IMRT segments were evaluated. For the delivery efficiency, the MUs were significantly higher in the sMLC-IMRT plan than in the mMLC-IMRT plan (802 ± 56.9 vs 702 ± 56.7; p < 0.05). The number of segments in the plans were 58.75 ± 1.8 and 59 ± 1.04 (p > 0.05). For the planning quality, the conformity index (CI) between the 2 paired IMRT plans with the mMLC and the sMLC did not differ significantly (average: 0.817 ± 0.024 vs 0.810 ± 0.028; p > 0.05). The differences of the homogeneity index (HI) between the 2 paired plans were statistically significant (average: 1.122 ± 0.010 vs 1.132 ± 0.014; p < 0.01). For OARs, the rectum, bladder, small intestine, and bony pelvis were evaluated in terms of V10, V20, V30, and V40, percentage of contoured OAR volumes receiving 10, 20, 30, and 40Gy, respectively, and the mean dose (Dmean) received. The IMRT plans with the mMLC protected the OARs better than the plans with the sMLC. There were significant differences (p < 0.05) in evaluated parameters between the 2 paired IMRT plans, except for V30 and V40 of the rectum and V10, V20, V40, and Dmean of the bladder. IMRT plans with the mMLC showed advantages over the plans with the sMLC in dose homogeneity for targets, dose sparing of OARs, and fewer MUs in cervical cancer.

High-precision MRI-guided adaptive brachytherapy for cervical carcinoma

Over the past 20 years advances in radiological technology have led to dramatic changes in cervical cancer management. External beam radiotherapy has evolved radically as a result of these changes. More recently, though, three-dimensional (3D) image guidance and volume-based prescribing has been adopted into cervical cancer brachytherapy. This overview covers the science and technology behind magnetic resonance imaging (MRI)-guided adaptive brachytherapy and explains why it is now considered the new international standard of care.

ACR Appropriateness Criteria® role of adjuvant therapy in the management of early stage cervical cancer

OBJECTIVE

The use of adjuvant treatment(s) following initial hysterectomy and retroperitoneal nodal harvesting of patients with clinical stage I and II cervical carcinoma is (are) presently based on the pathological assessment of surgical specimens. This report sought to delineate further the clinical application of potential therapeutic interventions and associated follow-up investigations of this patient cohort.

METHODS

The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journal and the application of a well-established consensus methodology (modified Delphi) to rate appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

RESULTS

From this process, 5 unique clinical variants were developed. These scenarios pertained to options of adjuvant radiation therapy and chemotherapy, methods of delivery of radiotherapy to optimize target volume coverage while simultaneously minimizing radiation exposure of adjacent healthy organs, and recommendations for patient follow-up care. Group members reached consensus of topic ratings in descending order of importance. A risk assessment breakdown was established to highlight the most likely indications for adjuvant treatment(s).

CONCLUSION

This assembly by the ACR of physicians involved in the management of patients with early stage cervical cancer was able to describe appropriateness criteria to aid other practitioners in selecting reasonable implementation of postoperative therapies and subsequent surveillance studies. These guidelines await further validation and refinement by both current and future prospectively randomized clinical studies regarding this patient population.

Modern Radiotherapy and Cervical Cancer

For most cervical cancers, radiotherapy is the mainstay of treatment. The introduction of concurrent chemotherapy to radiation at the end of the 20th century led to a significant improvement in disease survival. Now, techniques such as intensity-modulated radiotherapy, which allow a high degree of conformity to the tumor, offer the opportunity to further improve outcome by reducing treatment-related toxicity and also to potentially improve local control by an increase in tumor dose.

This review will outline the history and current state of play of cervical radiotherapy.

First quinquennial review of intensity-modulated radiotherapy at St Bartholomew's Hospital, London

Intensity-modulated radiotherapy (IMRT) is a relatively new technique of delivering external beam radiotherapy that is becoming increasingly available in the UK. This paper summarises the introduction and initial clinical work in IMRT over the period 2004-2009. Physics aspects of commissioning are described, including the development of a robust method of quality control using a sweeping gap test. Details of the organisational changes necessary to introduce IMRT are given. The clinical selection and practice in head and neck sites are described, together with promising early results on the maintenance of salivary flow after IMRT. A summary of research into optimal planning for pelvic cancer follows. The controversial areas of breast and paediatric IMRT are discussed with recommendations on practice. The potential for concomitant boost therapy is exemplified in the treatment of brain metastatic disease.