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Clinical analysis of prophylactic para-aortic intensity-modulated radiation in cervical cancer. Clin Radiol 2023; 78:e77-e84. [PMID: 36195500 DOI: 10.1016/j.crad.2022.08.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/18/2023]
Abstract
AIM This study aimed to compare the survival and toxicity of patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIIC cervical cancer without common iliac node metastasis treated with extended-field intensity-modulated radiotherapy (EF-IMRT) or pelvic IMRT (P-IMRT). MATERIALS AND METHODS Thirty-one patients treated with EF-IMRT and 37 patients who underwent P-IMRT were analysed retrospectively. Both groups were treated with high-dose-rate 192Ir two-dimensional brachytherapy and concurrent chemotherapy. The chi-square test and Kaplan-Meier method were used to compare toxicity and survival between the two groups. RESULTS The median follow-up time of EF-IMRT group and P-IMRT group was 22 and 30 months, respectively. The 3-year overall survival (OS), progression-free survival (PFS), and para-aortic lymph node metastasis-free survival (PAMFS) in the EF-IMRT group and P-IMRT group were 87% versus 74.6%, 83.6% versus 61.7%, and 96% versus 80.5%, respectively. Treatment regimens, tumour size, and radiation time were independent prognostic factors of OS and PFS. Treatment regimens, tumour size, and total equivalent dose in 2 Gy/f (EQD2) of point A were independent prognostic factors of PAMFS. Five patients in the EF-IMRT group and 14 patients in P-IMET group experienced treatment failure. The cumulative incidence of grade 3 and 4 acute leukopenia in the EF-IMRT group was 51.6%, in comparison with 27.03% in the pelvic group. No difference was found in thrombocytopenia between two groups. CONCLUSIONS Patients with FIGO 2009 stage IB1-IIIC cervical cancer without common iliac node metastases may be benefit from EF-IMRT. Notably, EF-IMRT exhibits increased toxicity incidence; however, this remains within an acceptable range.
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Bukkems LJ, Jürgenliemk-Schulz IM, van der Leij F, Peters M, Gerestein CG, Zweemer RP, van Rossum PS. The impact of para-aortic lymph node irradiation on disease-free survival in patients with cervical cancer: a systematic review and meta-analysis. Clin Transl Radiat Oncol 2022; 35:97-103. [PMID: 35669003 PMCID: PMC9166370 DOI: 10.1016/j.ctro.2022.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022] Open
Abstract
Standard of care of locally advanced cervical cancer is based on concurrent chemoradiotherapy. Para-aortic radiotherapy (PAO-RT) has become controversial in the chemotherapy era. Systematic review on impact of PAO-RT on disease-free survival yielded 11 studies. Meta-analysis of 3 studies showed pooled adjusted HR of 0.87 (95% CI: 0.79–0.97). Findings support further investigation in prospective controlled trials.
Background Patients with locally advanced cervical cancer without para-aortic lymph node metastases (PAO-LNM) at diagnosis who undergo concurrent chemoradiotherapy are at 4–11% risk of developing PAO-LNM during follow-up. Some studies suggest a beneficial influence of elective para-aortic radiotherapy (PAO-RT) on disease-free survival (DFS) in these patients. The aim of this study was to systematically review and meta-analyse literature on the impact of PAO-RT on DFS in cervical cancer patients. Methods A systematic search of PubMed/MEDLINE and EMBASE databases was performed. The analysis included intervention studies that reported on DFS in patients with cervical cancer who received chemotherapy and pelvic radiotherapy with or without PAO-RT. From each included study, relevant study characteristics and outcome data including the hazard ratio (HR) adjusted for potential confounders were extracted. An overall pooled adjusted hazard ratio (aHR) for DFS after PAO-RT versus no PAO-RT was calculated using a random-effects model. Results A total of 2,016 articles were evaluated. Eleven articles were included in the systematic review, of which 3 were appropriate for quantitative meta-analysis. Pooling of these 3 cohorts (including 1,113 patients) demonstrated a statistically significant association between PAO-RT and DFS (pooled aHR 0.87, 95% confidence interval: 0.79–0.97). No significant heterogeneity among reported aHRs was observed (I2 = 0.0%). Conclusions This meta-analysis suggests a modest but significant beneficial impact of elective para-aortic radiotherapy on DFS in patients with locally advanced cervical cancer who undergo concurrent chemoradiotherapy. This finding based on non-randomized studies provides an imperative for further investigation in prospective controlled trials.
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Affiliation(s)
- Leslie J.H. Bukkems
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Corresponding authors at: Department of Radiation Oncology, Q00.3.11, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands.
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis G. Gerestein
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ronald P. Zweemer
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter S.N. van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Corresponding authors at: Department of Radiation Oncology, Q00.3.11, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands.
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Horikawa N, Horie A, Kawahara S, Sunada M, Chigusa Y, Yamaguchi K, Hamanishi J, Kondo E, Mandai M. Feasibility of Laparoscopic Para-Aortic Lymphadenectomy for Locally Advanced Cervical Cancer. JSLS 2022; 26:JSLS.2021.00096. [PMID: 35444399 PMCID: PMC8993461 DOI: 10.4293/jsls.2021.00096] [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] [Indexed: 11/22/2022] Open
Abstract
Background Radiological evaluation of para-aortic lymph node metastasis in patients with locally advanced cervical cancer (LACC) possess the risk of missing microscopic metastasis. We commenced laparoscopic para-aortic lymphadenectomy (Lap-PAN) on patients with LACC for surgical staging in 2016. We assessed the feasibility of Lap-PAN in patients with LACC. Methods We retrospectively reviewed the records of 31 patients with LACC who were staged at International Federation of Gynecology and Obstetrics (FIGO) 2009 IIB to IVA without enlargement of the para-aortic lymph nodes who underwent radiation therapy in our hospital between January 1, 2011 and December 31, 2018. The postoperative outcomes of Lap-PAN were analyzed, and distinct parameters for each patient, including sites of recurrence and disease-free survival, were compared between the Lap-PAN (n = 12) and no surgery (n = 19) groups. Results The average operation time for Lap-PAN was 167 min, and the estimated blood loss was less than 50 ml in all patients. There were no perioperative complications. The average number of excised lymph nodes was 25, and no pathological metastases were observed. There was no difference in disease-free survival rates between the Lap-PAN and no surgery groups (p = 0.42). During the follow-up period, there were two cases of recurrence in the cervix in the Lap-PAN group, and three and four cases of lung and para-aortic lymph node recurrence, respectively in the no-surgery group. Conclusions Lap-PAN was safely performed as a pretherapeutic staging method for LACC without worsening patient prognosis. Although Lap-PAN requires a high level of skill, it may be a method to avoid excessive radiation for LACC.
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Affiliation(s)
- Naoki Horikawa
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Akihito Horie
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Shunsuke Kawahara
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Masumi Sunada
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Yoshitsugu Chigusa
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Ken Yamaguchi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Junzo Hamanishi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Eiji Kondo
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
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Zhang G, Wang C, Ma C, Miao L, He F, Fu C. A Novel Risk Factor for Para-Aortic Lymph Node Recurrence After Definite Pelvic Radiotherapy in Stage IIIB Cervical Cancer. Technol Cancer Res Treat 2022; 21:15330338221141541. [DOI: 10.1177/15330338221141541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Studies determining which patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB disease benefit from prophylactic extended-field irradiation (EFRT), which can reduce para-aortic lymph node (PALN) failure rates, are limited. The study was designed to evaluate the value of the controlling nutritional status (CONUT) score as a risk factor for predicting PALN recurrence and identifying potential indications of prophylactic EFRT. Methods: From 2010 to 2015, a retrospective review was conducted among patients with FIGO stage IIIB cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy. We analyzed para-aortic lymph node metastasis-free survival (PALNMFS) using Kaplan-Meier curves. Multivariate analyses were performed using Cox regression models. Results: A total of 116 patients with FIGO stage IIIB cervical cancer were included in the study and the median follow-up was 42.2 months (range: 3.5-104.2 months). Multivariate analysis revealed that the CONUT score (HR: 3.141; 95% CI: 2.321-5.436; P < .001) and ≥3 pelvic lymph node metastases (HR: 2.235; 95% CI: 1.428-11.242; P < .001) were independent risk predictors of PALNMFS. Compared with the low CONUT group (score<3), the high CONUT group (score≥3) was associated with a significantly worse 3-year disease-free survival rate (46.9 vs 69.5%, P = .001), a significantly lower 3-year overall survival rate (68.5 vs 79.7%, P = .016) and a significantly lower PALNMFS rate (74.8 vs 96.4%, P < .001). Conclusions: A high CONUT score (score≥3) and ≥3 pelvic metastatic lymph nodes were significant predictors of PALNMFS after pelvic radiation in FIGO stage IIIB cervical cancer patients. Patients with these risk factors might benefit from prophylactic EFRT.
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Affiliation(s)
- Guangyu Zhang
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Cong Wang
- Department of Gynecology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Changdong Ma
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Li Miao
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Fangfang He
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Chunli Fu
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Qilu Hospital of Shandong University, Jinan, China
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Upstaging by para-aortic lymph node dissection in patients with locally advanced cervical cancer: A systematic review and meta-analysis. Gynecol Oncol 2021; 164:667-674. [PMID: 34969533 DOI: 10.1016/j.ygyno.2021.12.026] [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: 10/08/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging (i.e. PET, CT, MRI) may miss para-aortic lymph node (PALN) metastases. The aim of this study was to systematically review and meta-analyze the proportion of upstaging by PALN dissection in patients with locally advanced cervical cancer without suspicious PALNs on imaging. METHODS PubMed/MEDLINE and Embase were systematically searched. The analysis included diagnostic studies that reported on 3D imaging and pre-therapeutic surgical assessment of PALN status in patients with cervical cancer. An overall pooled upstaging rate was calculated using a random-effects model. RESULTS The search identified 16 eligible studies including 18 cohorts with a total of 1530 patients. Pooling of 12 cohorts demonstrated an upstaging rate of 12% (95% confidence interval [CI] 10-15%) by PALN dissection after negative PET or PET-CT. Pooling of 6 cohorts demonstrated a pooled upstaging rate of 11% (95% CI: 8-16%) by PALN dissection after negative MRI or CT. No significant heterogeneity in upstaging proportions across cohorts was observed (I2 = 0% and 27%, respectively). In 7 cohorts including only patients with pelvic nodal metastases on imaging (but no suspicion of PALN involvement) a pooled upstaging rate by PALN dissection of 21% (95% CI: 17-26%) was found (I2 = 0%). CONCLUSIONS This meta-analysis demonstrates that in case of no suspicious PALN on PET-CT or MRI, PALN dissection still identifies lymph node metastases in a considerable amount of patients with locally advanced cervical cancer and especially in those patients with confirmed pelvic nodal metastases.
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Validation and applicability of para-aortic lymph nodal contouring atlas in cervical cancer. Radiother Oncol 2021; 165:32-36. [PMID: 34710510 DOI: 10.1016/j.radonc.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE CTV delineation guidelines for the para-aortic nodal region for patients with cervical cancer have been proposed (Keenan et al., 2018). The purpose of this study was to validate these guidelines with the use of CT datasets of cervical cancer patients with macroscopic PALN treated with definitive (chemo)radiation (CTRT) at our center. MATERIALS AND METHODS Planning CT datasets of 71 cervical cancer patients with gross PA nodal disease treated with EFRT were used. Two hundred and two PALN were identified based on size and morphology on diagnostic CECT, PET CT, or histologically proven PALN. LN regions were divided into upper, middle, and lower and based on their relation to the aorta and IVC. Macroscopic PALN were contoured, and the CTV for PALN irradiation was generated based on the proposed guidelines on ECLIPSE (Version 13.5). The centre of mass (COMN) was calculated for each gross PALN. The evaluation was done to review the presence of COMN in relation to the CTV PALN. RESULTS The most common location of PALN was Left para-aortic (105 LN-52%), Aortocaval (55 LN-27.2%), and Precaval (14 LN-6.9%). Lower PALN were the commonest (104 LN-51.5%). Ninety-three were middle PALN (46%), and 5 were upper PALN (2.5%). After excluding upper PALN, COMN for 11 PALN (5.5%) were outside the CTV while 20 were junctional. CONCLUSION Our study shows that more than 95% of PALN in this patient cohort were covered using these guidelines with the addition of an extra 5 mm margin laterally on the left.
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Huang X, Fang M, Zhu L, Gu C, Cui H, Yang C, Yang Y. Clinical Observation of Prophylactic Extended-Field Intensity-Modulated Radiation Therapy with Synchronous Chemotherapy in Locally Advanced Cervical Cancer. Med Sci Monit 2021; 27:e930457. [PMID: 34489390 PMCID: PMC8434770 DOI: 10.12659/msm.930457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 05/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We aimed to evaluate the value of prophylactic extended-field intensity-modulated radiation therapy (IMRT) in the treatment of locally advanced cervical cancer with multiple pelvic lymph node metastases (≥2) and negative common iliac and paraaortic lymph nodes. MATERIAL AND METHODS Thirty-four patient with newly diagnosed cervical cancer (IB1-IVA) and multiple pelvic lymph node metastases (≥2) confirmed by computed tomography and magnetic resonance imaging were randomly divided into an extended-field group (17 patients) and a pelvic-field group (17 patients). In the extended-field group, we added the drainage area of paraaortic lymph nodes on the pelvic field. The pelvic field was administered Dt 45.0 to 50.4 Gy, while the drainage area of paraaortic lymph nodes was administered Dt 40.0 to 45.0 Gy. Both groups were given Irl92 intracavitary radiotherapy after 3 weeks of external irradiation. The total dose of point A was 25.0 to 30.0 Gy, fractional 6.0 to 7.0 Gy. All patients had concurrent platinum-based chemotherapy once weekly until the end of radiotherapy. RESULTS No paraaortic lymph node metastasis was found in the extended-field group (P=0.0184), and disease-free survival (DFS) was prolonged (P=0.0286). Adverse effects in patients with III-IV degree myelosuppression were increased in the extended-field group (P=0.0324). However, all patients recovered after symptomatic treatment. CONCLUSIONS Prophylactic extended-field IMRT with chemotherapy reduced the metastasis rate of paraaortic lymph nodes and prolonged the DFS in patients with locally advanced cervical cancer and multiple pelvic lymph node metastases (≥2), while the toxic adverse effects were tolerated.
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Affiliation(s)
- Xue Huang
- Department of Gynecology and Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Mingming Fang
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Lin Zhu
- Department of Gynecology and Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Cheng Gu
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Han Cui
- Department of Gynecology and Oncology, Changxing County People’s Hospital, Huzhou, Zhejiang, PR China
| | - Chun Yang
- Department of Obstetrics and Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, PR China
| | - Yuxing Yang
- Department of Gynecology and Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
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Peters M, de Leeuw AAC, Nomden CN, Tanderup K, Kirchheiner K, Lindegaard JC, Kirisits C, Haie-Meder C, Sturdza A, Fokdal L, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Huang F, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters BR, Tan LT, van Rossum PSN, Nesvacil N, Nout R, Schmid MP, Pötter R, Jürgenliemk-Schulz IM. Risk factors for nodal failure after radiochemotherapy and image guided brachytherapy in locally advanced cervical cancer: An EMBRACE analysis. Radiother Oncol 2021; 163:150-158. [PMID: 34480958 DOI: 10.1016/j.radonc.2021.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess risk factors for nodal failure (NF) after definitive (chemo)radiotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) for patients treated in the EMBRACE I study. MATERIALS AND METHODS Data for pelvic NF and para-aortic (PAO) NF (NFPAO) were analysed. After multiple imputation, univariable and multivariable Cox-regression was performed for clinical and treatment-related variables. For patients with affected pelvic nodes but no PAO nodes at diagnosis, additional analyses were performed for two subgroups: 1. 'small pelvis' nodes in internal and external iliac, obturator, parametrial, presacral and/or common iliac (CI) region and 2. any CI nodes (subgroup of 1). RESULTS 1338 patients with 152 NF and 104 NFPAO events were analysed with a median follow-up of 34.2 months (IQR 16.4-52.7). For the entire group, larger tumour width, nodal risk groups (in particular any CI nodes without PAO nodes), local failure, and lower Hb-nadir increased the risk of NF. Elective PAO-irradiation was independently associated with a decreased risk of NFPAO (HR 0.53, 95%-CI 0.28-1.00, p = 0.05). For subgroup 1, having 'any CI nodes without PAO nodes' and local failure significantly increased NF risk. Additionally, elective PAO-irradiation was associated with less risk of NFPAO (HR 0.38, 95%-CI 0.17-0.86, p = 0.02). For subgroup 2 only local failure was associated with higher risk of NF. CONCLUSION In this patient cohort, nodal disease and tumour width at diagnosis, as well as local failure, are risk factors for NF after definitive treatment. Having either 'any PAO nodes' (with or without pelvic nodes) or 'any CI nodes' (without PAO nodes) are stronger risk factors than involvement of nodes in the small pelvis alone. Elective PAO-irradiation was associated with significantly less NFPAO, particularly in patients with nodal disease in the 'small pelvis' and/or CI region at time of diagnosis.
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Affiliation(s)
- Max Peters
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| | - Astrid A C de Leeuw
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Christel N Nomden
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Lars Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | | | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Barbara Segedin
- Institute of Oncology Ljubljana, Department of Radiotherapy, Ljubljana, Slovenia
| | - Kjersti Bruheim
- The Norwegian Radium Hospital-Oslo University Hospital, Department of Oncology, Oslo, Norway
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Department of Radiotherapy and Oncology, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Li Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom
| | - Peter S N van Rossum
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Remi Nout
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
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Kim N, Park W. Patterns of definitive radiotherapy practice for cervical cancer in South Korea: a survey endorsed by the Korean Radiation Oncology Group (KROG 20-06). J Gynecol Oncol 2021; 32:e43. [PMID: 33825358 PMCID: PMC8039174 DOI: 10.3802/jgo.2021.32.e43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The Korean Radiation Oncology Group conducted a nationwide questionnaire survey to evaluate the patterns of clinical practice for patients with cervical cancer receiving definitive radiation therapy (RT) in South Korea. Methods Practicing radiation oncologists from 93 centers in South Korea were administered a questionnaire survey via e-mail. The survey focused on demographic characteristics, diagnostic evaluation, indications for definitive RT, RT techniques, RT field and dose prescription, lymph node (LN) boost RT, brachytherapy, and chemotherapy. Results The response rate was 62.4% (58/93 institutions). Of the 2,134 patients treated at the radiation oncology department in 2019, 48.8% underwent definitive RT. The selection of patients for definitive concurrent chemoradiation therapy and RT field, and RT dose prescription varied greatly. The upper border of the pelvis was commonly used as the bony landmark for external beam RT (81%–88% of respondents). Most (96.6%) centers performed LN boost RT with median total doses of 59 Gy and 59.2 Gy for pelvic and retroperitoneal LN, respectively. With 50% of the centers offering brachytherapy, image-guided brachytherapy and volume-based prescription were applied in 48.3% and 37.9%, respectively. Upfront concurrent chemoradiation therapy with varying prescription doses was considered by 60.4% respondents in cases of supraclavicular LN metastasis. Conclusion Most differences were noted in the indications for treatment, RT field, and prescription dose. This finding can serve as a reference for establishing practical RT guidelines for the management of locally advanced cervical cancer.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Fabian A, Krug D, Alkatout I. Radiotherapy and Its Intersections with Surgery in the Management of Localized Gynecological Malignancies: A Comprehensive Overview for Clinicians. J Clin Med 2020; 10:E93. [PMID: 33383960 PMCID: PMC7796321 DOI: 10.3390/jcm10010093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023] Open
Abstract
Surgery, including minimally invasive surgery, and radiotherapy are key modalities in the treatment of gynecological malignancies. The aim of this review is to offer the multidisciplinary care team a comprehensive summary of the intersections of surgery and radiotherapy in the local treatment of gynecological malignancies. Recent advances in radiotherapy are highlighted. Relevant publications were identified through a review of the published literature. Ovarian, endometrial, cervical, vaginal, and vulvar cancer were included in the search. Current guidelines are summarized. The role of radiotherapy in adjuvant as well as definitive treatment of these entities is synthesized and put into context with surgery, focusing on survival and quality of life. Although these outcomes have improved recently, further research must be focused on the number of life years lost, and the potential morbidity encountered by patients.
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Affiliation(s)
- Alexander Fabian
- Department of Radiation Oncology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105 Kiel, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105 Kiel, Germany;
| | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105 Kiel, Germany
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Wang W, Zhou Y, Wang D, Hu K, Zhang F. Prophylactic Extended-Field Irradiation in Patients With Cervical Cancer: A Literature Review. Front Oncol 2020; 10:579410. [PMID: 33123482 PMCID: PMC7567016 DOI: 10.3389/fonc.2020.579410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/14/2020] [Indexed: 11/13/2022] Open
Abstract
Currently, the standard radiation field for locally advanced cervical cancer patients without evidence of para-aortic lymph node (PALN) metastasis is the pelvis. Due to the low accuracy of imaging in the diagnosis of PALN metastasis and the high incidence of PALN failure after pelvic radiotherapy, prophylactic pelvic and para-aortic irradiation, also called extended-field irradiation (EFI), is performed for patients with cervical cancer. In the era of concurrent chemoradiotherapy, randomized controlled trials are limited, and whether patients with cervical cancer can benefit from prophylactic EFI is still controversial. With conformal or intensity-modulated radiation therapy, patients tolerate prophylactic EFI very well. The severe toxicities of prophylactic EFI are not significantly higher than those of pelvic radiotherapy. We recommend delivering prophylactic EFI to cervical cancer patients with common iliac lymph nodes metastasis. Clinical trials are needed to investigate whether patients with ≥3 positive pelvic lymph nodes and FIGO stage IIIB disease can benefit from prophylactic EFI. According to the distribution of PALNs, it is reasonable to use the renal vein as the upper border of the radiation therapy field for patients treated with prophylactic EFI. The clinical target volume expansion of the node from the vessel should be smaller in the right para-caval region than in the left lateral para-aortic region. The right para-caval region above L2 or L3 may be omitted from the PALN target volume to reduce the dose to the duodenum. More clinical trials on prophylactic EFI in cervical cancer are needed.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuncan Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Wang W, Wang D, Liu X, Zhou Y, Ma J, Hou X, Hu K, Zhang F. Risk factors associated with Para-Aortic Lymph Node Failure after pelvic irradiation in patients with Cervical Cancer. J Cancer 2020; 11:5099-5105. [PMID: 32742457 PMCID: PMC7378915 DOI: 10.7150/jca.45520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/14/2020] [Indexed: 12/24/2022] Open
Abstract
Objective: Previous studies have shown that prophylactic extended-field irradiation can reduce para-aortic lymph node failure (PALNF) rates in patients with cervical cancer. As such, this type of irradiation may particularly benefit patients with a high risk of PALNF. In the present study, we analyzed the risk factors for PALNF in patients with cervical cancer treated with pelvic irradiation in order to identify potential indications of prophylactic extended-field irradiation. Methods: We evaluated patients with 2018 FIGO stage IB3-IIIC1 cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy at our institution between 2011 and 2014. Univariate and multivariate analyses were performed to identify risk factors for PALNF. Results: We included 572 patients in the study. The median follow-up period was 37.9 months. Eighteen patients (3.1%) first site of tumor relapse was the para-aortic lymph nodes, and thus showed PALNF. Using multivariate Cox regression analysis, we identified two significant risk factors for PALNF: tumor extension to the pelvic wall (hazard ratio, HR 3.60, p=0.026) and ≥ 2 pelvic MLNs (HR 5.30, p=0.005). For patients with and without risk factors, the 3-year overall survival, disease-free survival, and PALNF rates were 77.3% and 90.1% (p<0.001), 56.4% and 83.1% (p<0.001), and 12.0% and 2.3% (p<0.001), respectively. Conclusion: Tumor extension to the pelvic wall and ≥ 2 pelvic MLNs are positively associated with PALNF after pelvic irradiation in patients with cervical cancer. Further trials will be required to validate whether patients with these two risk factors may benefit from prophylactic extended-field irradiation.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuncan Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiabin Ma
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Yang B, Liu X, Hu K, Qiu J, Zhang F, Hou X, Yan J, Meng Q, Wang W, Yu L, Wang Y. Reduction of dose to duodenum with a refined delineation method of Para-aortic region in patients with locally advanced cervical Cancer receiving prophylactic extended-field radiotherapy. Radiat Oncol 2019; 14:196. [PMID: 31703705 PMCID: PMC6839216 DOI: 10.1186/s13014-019-1398-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/16/2019] [Indexed: 12/03/2022] Open
Abstract
Background To compare irradiation dose to the second and third portions of duodenum (Duo2 and Duo3) with a new refined and old delineation method of para-aortic region for patients with locally advanced cervical cancer (LACC) receiving prophylactic extended-field radiotherapy (EFRT). Methods Twenty consecutive patients with LACC were treated with prophylactic EFRT from January 2016 to January 2017 at our institute. Two delineation methods of para-aortic region were designed for each patient, the old delineation method ensured a full coverage of aortic and inferior vena cava, while the right paracaval region above L3 was omitted from CTV in the new delineation method. Patients received a dose of 50.4Gy in 28 fractions for PCTV and a dose of 60.2Gy in 28 fractions for PGTV with volumetric-modulated arc therapy (VMRT). The dose delivered to Duo2 and Duo3 with these two delineation methods were compared. Results All treatment plans achieved excellent target volume coverage with 95% of PCTV receiving 50.4Gy and 95% of PGTV receiving 60.2Gy. There was no difference between delineation methods in low dose level (V5, V10, V15, V20, V25) for Duo2 and Duo3. The V30, V35, V40, V45, V50, Dmax, Dmean and D2cc for Duo2 with the new and old delineation methods were 55.76% vs 80.54% (P = 0.009), 34.72% vs 70.91% (P < 0.001), 18.69% vs 55.46% (P < 0.001), 8.20% vs 41.49% (P < 0.001), 1.86% vs 21.60% (P < 0.001), 49.58Gy vs 52.91Gy (P = 0.002), 30.38Gy vs 39.22Gy (P = 0.001) and 37.90Gy vs 48.64Gy (P < 0.001) respectively. For Duo3, the new delineation method achieved significant advantages in V30, V35, V40, V45, V50 and Dmean over the old one (96.82% vs 99.25%, P = 0.021; 89.65% vs 97.21%, P = 0.001; 79.50% vs 93.18%, P < 0.001; 65.63% vs 82.93%, P < 0.001; 43.39% vs 65.60%, P < 0.001; 46.09Gy vs 49.24Gy, P < 0.001), no deference was observed regarding D2cc and Dmax with these two delineation methods. Conclusion With the new delineation method of para-aortic area in prophylactic EFRT, significant reduction of irradiation dose to the second and third portions of duodenum in high dose area was obtained. This may further lower the incidence of duodenal toxicity when performing prophylactic EFRT for patients with LACC.
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Affiliation(s)
- Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730.
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730.
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Qingyu Meng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Yijun Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
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Prophylactic Extended-Field Irradiation for Patients With Cervical Cancer Treated With Concurrent Chemoradiotherapy: A Propensity-Score Matching Analysis. Int J Gynecol Cancer 2019; 28:1584-1591. [PMID: 30153215 PMCID: PMC6166702 DOI: 10.1097/igc.0000000000001344] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Supplemental digital content is available in the text. Objective The aim of the study was to evaluate the efficacy and toxicity of prophylactic extended-field radiation therapy (RT) for cervical cancer patients treated with concurrent chemoradiotherapy (CCRT). Methods Records of patients with cervical cancer without para-aortic metastatic lymph nodes who were treated with definitive RT or CCRT between January 2011 and December 2014 were reviewed. Patients were classified into the pelvic RT and extended-field RT groups. An additional dose of 50.4 Gy in 28 fractions was delivered to para-aortic lymph node regions for patients in the extended-field RT group. Cox regression and propensity-score matching (1:1) were used to compare the overall survival (OS), disease-free survival (DFS), distant failure, and para-aortic lymph node failure (PALNF) between the pelvic RT and extended-field RT groups. Results A total of 778 patients were analyzed. Of them, 624 patients were treated with pelvic RT and 154 patients received extended-field RT. The median follow-up period was 37.5 months. In multivariate analysis, extended-field RT was an independent prognostic factor of distant failure (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.26–0.90, P = 0.023) and PALNF (HR = 0.012, 95% CI = 0.00–0.49, P = 0.019). However, it was not significant in predicting OS (P = 0.546) and DFS (P = 0.187). With propensity-score matching, 108 pairs of patients were selected. The 3-year OS, DFS, local control, distant failure, and PALNF rates in the pelvic RT and extended-field RT groups were 87.1% and 85.7% (P = 0.681), 71.0% and 80.6% (P = 0.199), 86.6% and 85.0% (P = 0.695), 21.7% and 7.0% (P = 0.016), and 6.6% and 0% (P = 0.014), respectively. The incidences of grade 3 or greater chronic toxicities were 3.5% and 6.5% in the pelvic RT and extended-field RT groups, respectively (P = 0.097). Conclusions Prophylactic extended-field RT was associated with decreased distant failure and PALNF and showed a trend in improving DFS in patients with cervical cancer treated with CCRT.
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Poitevin Chacón A, Chavez-Nogueda J, Ramos-Prudencio R, Villavicencio-Queijeiro MA, Lozano-Ruiz F. The role of para-aortic nodal irradiation in cervical cancer. Rep Pract Oncol Radiother 2018; 23:540-546. [PMID: 30534018 DOI: 10.1016/j.rpor.2018.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 08/13/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022] Open
Abstract
The current standard of care for locally advanced cervical cancer is whole pelvis and para-aortic radiation when indicated, delivered concomitantly with chemotherapy and brachytherapy. Para-aortic node involvement is a predictor of survival in locally advanced disease but presence of metastases is difficult to determine because the currently available imaging methods lack enough sensitivity to be able to detect accurately para-aortic metastases when surgical staging is not feasible. The objective of this review is to describe the current status of para-aortic lymph node irradiation in locally advanced cervical cancer. It includes analysis of the diagnostic imaging and surgical approaches for assessment of para-aortic lymph node dissemination, together with indications for radiotherapy and radiotherapeutic techniques.
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Elit LM, Fyles AW, Gu CS, Pond GR, D’Souza D, Samant R, Anthes M, Thomas G, Filion M, Arsenault J, Dayes I, Whelan TJ, Gulenchyn KY, Metser U, Dhamanaskar K, Levine MN. Effect of Positron Emission Tomography Imaging in Women With Locally Advanced Cervical Cancer: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e182081. [PMID: 30646153 PMCID: PMC6324512 DOI: 10.1001/jamanetworkopen.2018.2081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In women with locally advanced cancer of the cervix (LACC), staging defines disease extent and guides therapy. Currently, undetected disease outside the radiation field can result in undertreatment or, if disease is disseminated, overtreatment. OBJECTIVE To determine whether adding fludeoxyglucose F 18 positron emission tomography-computed tomography (PET-CT) to conventional staging with CT of the abdomen and pelvis affects therapy received in women with LACC. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted. Women with newly diagnosed histologically confirmed International Federation of Gynecology and Obstetrics stage IB to IVA carcinoma of the cervix who were candidates for chemotherapy and radiation therapy (CRT) were allocated 2:1 to PET-CT plus CT of the abdomen and pelvis or CT alone. Enrollment occurred between April 2010 and June 2014 at 6 regional cancer centers in Ontario, Canada. The PET-CT scanners were at 6 associated academic institutions. The median follow-up at the time of the analysis was 3 years. The analysis was conducted on March 30, 2017. INTERVENTIONS Patients received either PET-CT plus CT of the abdomen and pelvis or CT of the abdomen and pelvis. MAIN OUTCOMES AND MEASURES Treatment delivered, defined as standard pelvic CRT vs more extensive CRT, ie, extended field radiotherapy or therapy with palliative intent. RESULTS One hundred seventy-one patients were allocated to PET-CT (n = 113) or CT (n = 58). The trial stopped early before the planned target of 288 was reached because of low recruitment. Mean (SD) age was 48.1 (11.2) years in the PET-CT group vs 48.9 (12.7) years in the CT group. In the 112 patients who received PET-CT, 68 (60.7%) received standard pelvic CRT, 38 (33.9%) more extensive CRT, and 6 (5.4%) palliative treatment. The corresponding data for the 56 patients who received CT alone were 42 (75.0%), 11 (19.6%), and 3 (5.4%). Overall, 44 patients (39.3%) in the PET-CT group received more extensive CRT or palliative treatment compared with 14 patients (25.0%) in the CT group (odds ratio, 2.05; 95% CI, 0.96-4.37; P = .06). Twenty-four patients in the PET-CT group (21.4%) received extended field radiotherapy to para-aortic nodes and 14 (12.5%) to common iliac nodes compared with 8 (14.3%) and 3 (5.4%), respectively, in the CT group (odds ratio, 1.64; 95% CI, 0.68-3.92; P = .27). CONCLUSIONS AND RELEVANCE There was a trend for more extensive CRT with PET-CT, but the difference was not significant because the trial was underpowered. This trial provides information on the utility of PET-CT for staging in LACC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00895349.
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Affiliation(s)
- Lorraine M. Elit
- Juravinski Cancer Centre, Department of Obstetrics & Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Anthony W. Fyles
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Gregory R. Pond
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David D’Souza
- London Regional Cancer Centre, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - Rajiv Samant
- Ottawa Hospital Cancer Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Margaret Anthes
- Thunder Bay Regional Cancer Centre, Thunder Bay, Ontario, Canada
| | - Gillian Thomas
- Odette Sunnybrook Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Marc Filion
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Julie Arsenault
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Ian Dayes
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J. Whelan
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Karen Y. Gulenchyn
- Hamilton Health Sciences, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ur Metser
- Princess Margaret Hospital, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Kavita Dhamanaskar
- Hamilton Health Sciences, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Mark N. Levine
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Nomogram for predicting para-aortic lymph node metastases in patients with cervical cancer. Arch Gynecol Obstet 2018; 298:381-388. [DOI: 10.1007/s00404-018-4829-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/18/2018] [Indexed: 01/15/2023]
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Novikov SN, Krzhivitskii PI, Kanaev SV, Berlev IV, Kargopolova MV, Ibragimov Z, Bisyarin M, Saveleva VV. Lymph flow guided irradiation of regional lymph nodes in patients with cervical cancer: Preliminary analysis of scintigraphic data. Rep Pract Oncol Radiother 2018; 23:503-509. [PMID: 30534013 DOI: 10.1016/j.rpor.2018.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 03/26/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate patterns of lymph flow from primary lesions in patients with cervical cancer and to determine how useful for radiotherapy planning this information can be. Materials and methods SPECT-CT visualization of sentinel (SLN) lymph nodes (LNs) was performed in 36 primary patients with IB-IIB cervical cancer. The acquisition started 120-240 min after 4 peritumoral injections of 99mTc-radiocolloids (150-300 MBq in 0.4-1 ml). We determined localization of LN with uptake of radiocolloids, type of lymph flow (mono-, bi-lateral) and lymph flow patterns (supraureteral paracervical, infraureteral paracervical and directly to para-aortic LNs). Results SLNs were visualized in 31 of 36 women. Bilateral lymph-flow was detected in 22 (71%), monolateral - in the other 9 (29%) cases. The distribution of SLNs was as follows: external iliac - 64.5%, internal iliac - 54.8%, obturator - 32.2%, common iliac - 35.5% and pre-sacral 3.2%. Para-aortic LNs were visualized in 5 (16.1%) patients. The supraureteral paracervical pattern of lymph flow was identified in 22, infraureteral paracervical - in 4 and their combination - in the other 5 women. Conclusion Visualization of an individual pattern of lymph flow from primary cervical cancer can be considered as a promising tool for optimization of the volume of irradiated regional LNs.
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Affiliation(s)
- Sergey Nikolaevich Novikov
- Department of Radiation Oncology & Nuclear Medicine, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Pavel Ivanovich Krzhivitskii
- Department of Radiation Oncology & Nuclear Medicine, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Sergey Vasilevich Kanaev
- Groups of Radiology, Radiation Oncology & Nuclear Medicine, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Igor Viktorovitch Berlev
- Department of Oncogynecology, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Margarita Viktorovna Kargopolova
- Department of Radiation Oncology & Nuclear Medicine, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Zaur Ibragimov
- Department of Oncogynecology, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Mikhail Bisyarin
- Department of Radiation Oncology & Nuclear Medicine, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
| | - Valentina Vladimirovna Saveleva
- Department of Radiation Oncology & Nuclear Medicine, N.N. Petrov Institute Oncology, Leningradskaya 68, 197758 St Petersburg, Russia
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An atlas to aid delineation of para-aortic lymph node region in cervical cancer: Design and validation of contouring guidelines. Radiother Oncol 2018. [PMID: 29523410 DOI: 10.1016/j.radonc.2018.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Previous studies have investigated the anatomical distribution of para-aortic lymph nodes (PAN) in patients with cervical cancer. However, an atlas for accurate clinical target volume (CTV) delineation has yet to be defined. The purpose of this study was to design and verify a computerized tomography (CT) atlas to provide guidance for contouring the PAN CTV in patients with cervical cancer. MATERIALS AND METHODS This prospective study included 21 cervical cancer patients (design cohort) with 39 pathological PAN identified on (18)F-FDG PET-CT. PAN [left lateral para-aortic (LLPA), aorto-caval (AC), right para-caval (RPC) nodes] were delineated on CT simulation scans. Measurements were taken from the volumetric centre of the nodes to the edge of aorta and inferior vena-cava (IVC). Initially the aorta and IVC were expanded by the mean distance to the lymph node centre to create a CTV. Expansion margins were then increased asymmetrically until the CTV resulted in a clinically acceptable number of PAN included. The CTV was validated on a further 10 patients (validation cohort) with 29 PAN. A detailed contouring guide and accompanying visual atlas for elective PAN CTV delineation was created based on the validated margins. RESULTS For the design cohort (n = 21 patients, 39 PAN), the mean distance from the centre of the node to the aorta was 8 mm (range 4-17) for both LLPA (range 4-17) and AC (range 4-15) regions. Mean distance from the IVC to the centre of the nodes was 5 mm (range 4-6) in the RPC region and 6 mm (range 3-15) in the AC region. No PAN was superior to the T12-L1 interspace or the left renal vein or inferior to the L5-S1 interspace. For validation cohort (n = 10 patients, 29 PAN), mean distance from centre of the node to the aorta was 9 mm (range 5-15) in the LLPA region, 7 mm (range 6.5-14) in the AC region. Mean distance from the ICV to the centre of the nodes was 3 mm (range 2.5-4) in the RPC region and 5 mm (range 3-10) in the AC region. A CTV expansion from the aorta of 10 mm circumferentially and 15 mm laterally, and from the IVC of 8 mm anteromedially and 6 mm posterolaterally resulted in coverage of 97% (38/39) of PAN in the design cohort. On prospective validation, the described CTV included 97% (28/29) of PAN in the validation cohort. CONCLUSION We propose the following PAN CTV; expansion from aorta of 10 mm circumferentially except 15 mm laterally, expansion from the IVC of 8 mm anteromedial and 6 mm posterolaterally. The suggested CTV includes 97% (28/29) PAN in a validated patient cohort. A detailed guide and accompanying visual atlas is provided to aid delineation of the PAN CTV in patients with cervical cancer.
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Management of Para-aortic Lymph Node Disease in Patients With Cervical Cancer: What Is the Best Approach? Int J Gynecol Cancer 2018; 27:543-549. [PMID: 28107261 DOI: 10.1097/igc.0000000000000914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Cervical cancer remains a prevalent and deadly disease in low-income countries, especially among young and otherwise healthy women. Multimodality treatment has led to a significant improvement in outcomes for patients with locally advanced disease, and this is mainly because of the incorporation of platinum-based chemoradiotherapy in current treatment protocols. However, locally advanced tumors are associated with a greater risk for para-aortic lymph node (PALN) involvement, which is an important adverse prognostic factor. Most staging techniques have low accuracy for detection of disease in this area, which could lead to understaging and undertreatment. Meanwhile, patients with PALN disease are underrepresented in trials addressing the treatment of advanced cervical cancer and a few studies have been directed at this population. The aim of this review is to analyze the current data regarding staging and treatment of cervical cancer with PALN disease to determine which strategy is best when managing these patients.
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Oh J, Seol KH, Lee HJ, Choi YS, Park JY, Bae JY. Prophylactic extended-field irradiation with concurrent chemotherapy for pelvic lymph node-positive cervical cancer. Radiat Oncol J 2017; 35:349-358. [PMID: 29262671 PMCID: PMC5769878 DOI: 10.3857/roj.2017.00367] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 01/22/2023] Open
Abstract
Purpose This study aimed to evaluate whether prophylactic extended-field pelvic radiotherapy (EF-PRT) yields better results than standard whole pelvic radiotherapy (WPRT) in patients with pelvic lymph node-positive cervical cancer treated with concurrent chemoradiotherapy (CCRT). Materials and Methods A total of 126 cases of stage IB-IVA cervical cancer that had pelvic lymph node involvement in magnetic resonance imaging and were treated with CCRT between 2000 and 2016 were reviewed. None of the patients had paraaortic lymph node (PALN) metastases. The patients were classified to two groups, namely, those treated with EF-PRT, including prophylactic para-aortic radiotherapy, and those treated only with WPRT. The median dose to the PALN area in patients treated with EF-PRT was 45 Gy. All patients received concurrent cisplatin-based chemotherapy. Results Overall, 52 and 74 patients underwent EF-PRT and WPRT, respectively. Patient characteristics and irradiated dose were not significantly different, except the dose to the para-aortic area, between the two groups. The median follow-up period was 75.5 months (range, 5 to 195 months). The 10-year cumulative recurrence rate of PALN for EF-PRT vs. WPRT was 6.9% and 10.1% (p = 0.421), respectively. The 10-year disease-free survival and overall survival for EF-PRT vs. WPRT were 69.7% vs. 66.1% (p = 0.748) and 71.7% vs. 72.3% (p = 0.845), respectively. Acute gastrointestinal complications were significantly higher in EF-PRT (n = 21; 40.4%) than WPRT (n = 26; 35.1%) (p = 0.046). Late toxicities were not significantly different in both groups. Conclusion In this study, prophylactic radiotherapy for PALN does not have an additional benefit in patients with pelvic lymph node-positive cervical cancer treated with CCRT.
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Affiliation(s)
- Jinju Oh
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Ho Seol
- Department of Radiation Oncology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hyun Joo Lee
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Youn Seok Choi
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ji Y Park
- Department of Pathology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jin Young Bae
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
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Atri M, Zhang Z, Dehdashti F, Lee SI, Ali S, Marques H, Koh WJ, Moore K, Landrum L, Kim JW, DiSilvestro P, Eisenhauer E, Schnell F, Gold M. Utility of PET-CT to evaluate retroperitoneal lymph node metastasis in advanced cervical cancer: Results of ACRIN6671/GOG0233 trial. Gynecol Oncol 2016; 142:413-9. [PMID: 27178725 DOI: 10.1016/j.ygyno.2016.05.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess if FDG PET combined with diagnostic CT improves diagnostic CT accuracy to detect lymph node (LN) metastasis in advanced cervical cancer. METHODS A prospective HIPAA compliant ACRIN/GOG multicenter trial was conducted. Patients underwent concurrent diagnostic contrast-enhanced CT (DCT) and PET and pelvic/abdominal lymphadenectomy. Seven independent blinded readers reviewed PET-DCT and DCT one-month apart. Reference standard was surgically removed LN pathology. Accuracy values were calculated at participant level, correlating abdominal (right and left para-aortic/common iliac) and pelvic (right and left external iliac/obturator) LN regions with pathology, respecting laterality. Reader average sensitivities/specificities of PET-DCT vs. DCT were compared with generalized linear mixed models, and AUCs with Obuchowski's method. RESULTS One hundred fifty-three patients had PET-DCT and pathology. Forty-three of 153 patients had metastasis to abdominal LNs. Sample size calculation required review of the first 40 abdominal positive and 40 randomly selected abdominal negative studies. Patients were 24 to 74years (48.9±10.6) old. Mean sensitivities of PET-DCT/DCT for detection of LN metastasis in abdomen were 0.50 (CI: 0.44, 0.56) and 0.42 (CI: 0.36, 0.48) (p=0.052) and in pelvis 0.83 (CI: 0.78, 0.87) and 0.79 (CI: 0.73, 0.83) (p=0.15). Corresponding specificities were 0.85 (CI: 0.80, 0.89) and 0.89 (CI: 0.84, 0.92) (p=0.21) and 0.63 (CI: 0.54, 0.70) and 0.62 (CI: 0.53, 0.69) (p=0.83). Mean AUC values were 0.70 (CI: 0.61, 0.79) and 0.68 (CI: 0.59, 0.77) (p=0.43) and 0.80 (CI: 0.71, 0.88) and 0.76 (CI: 0.67, 0.85) (p=0.21) respectively. CONCLUSION Addition of PET to DCT resulted in statistically borderline increase in sensitivity to detect LN metastasis in abdomen in advanced cervical cancer.
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Affiliation(s)
| | | | | | | | | | | | | | - Kathleen Moore
- University of Oklahoma Health Science Center, United States
| | - Lisa Landrum
- University of Oklahoma Health Science Center, United States
| | - Jae Weon Kim
- Seoul National University College of Medicine, Republic of Korea
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Kim JH, Kim JY, Yoon MS, Kim YS, Lee JH, Kim HJ, Kim H, Kim YJ, Yoo CW, Nam BH, Kim TH, Kim SK, Kim SH, Kang S, Seo SS, Lim MC, Park SY. Prophylactic irradiation of para-aortic lymph nodes for patients with locally advanced cervical cancers with and without high CA9 expression (KROG 07-01): A randomized, open-label, multicenter, phase 2 trial. Radiother Oncol 2016; 120:383-389. [PMID: 27102843 DOI: 10.1016/j.radonc.2016.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/30/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE The efficacy of prophylactic extended-field irradiation (EFI) plus concomitant cisplatin in patients with locally advanced uterine cervical cancer (LAUCC) is unknown, nor is it known whether tumor carbonic anhydrase IX (CA9) expression level, a hypoxia marker, influences survival outcome. MATERIAL AND METHODS We recruited patients with UCC, FIGO stage IB1 with pelvic lymph node (LN) metastases to IVA with negative para-aortic LN on PET/CT. CA9 expression was examined and patients were randomized to either EFI or pelvic only radiotherapy (PRT) in each CA9 group. The primary outcomes were para-aortic recurrence-free survival (PARFS) and disease-free survival (DFS). RESULTS Between 2006 and 2011, 79 patients with CA9-positive and 37 with CA9-negative tumors were enrolled, respectively. The median follow-up period was 69.2months (range 6.8-102.1). For CA9-positive patients, 5-year PARFS was 100% and 81.7% for those receiving EFI and PRT (p=0.007), respectively. DFS was 78.6% for EFI and 71.3% for PRT patients (p=0.353). For CA9-negative patients, 5y PARFS was 100% and 94.1% for EFI and PRT (p=0.317), respectively. DFS was 100% for EFI and 70.7% for PRT (p=0.018). CONCLUSION EFI significantly reduced recurrences in PAN in patients with CA9-positive tumors, but survival outcome was not improved, due to high local recurrence and high distant metastases rates. This study indicates the necessity for new therapeutic strategies for LAUCC patients whose tumors show high CA9 expression.
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Affiliation(s)
- Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Joo-Young Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University, Hwasun Hospital, Republic of Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, Unviersity of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University, Republic of Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University, College of Medicine, Republic of Korea
| | - Hunjung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University, School of Medicine, Incheon, Republic of Korea
| | - Yeon-Joo Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Chong Woo Yoo
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Byung-Ho Nam
- Cancer Control and Policy Department, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Republic of Korea
| | - Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Suk-Ki Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sun Ho Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Seokbom Kang
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sang Soo Seo
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Myong Cheol Lim
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sang-Yoon Park
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
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Kobayashi R, Yamashita H, Okuma K, Ohtomo K, Nakagawa K. Details of recurrence sites after definitive radiation therapy for cervical cancer. J Gynecol Oncol 2015; 27:e16. [PMID: 26463432 PMCID: PMC4717221 DOI: 10.3802/jgo.2016.27.e16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/09/2015] [Accepted: 09/15/2015] [Indexed: 12/04/2022] Open
Abstract
Objective This is a retrospective study aimed at clarifying the details of recurrence patterns and sites in patients with cervical cancer treated with definitive radiation therapy (RT). Methods Data were analyzed from consecutive patients, admitted to the University of Tokyo Hospital (Tokyo, Japan) between 2001 and 2013, who had received definitive RT, with or without chemotherapy, for International Federation of Gynecology and Obstetrics stages IB–IVA cervical cancer. Results One hundred and thirty-seven patients formed the patient cohort. The median follow-up period for surviving patients was 57.0 months. A complete response was achieved in 121 patients (88%). Of these, 36 (30%) developed a cancer recurrence during follow-up. The first sites of recurrence were located in intra-RT fields in nine, outside RT fields in 20, and both in seven patients. In the intra-RT field group, all patients showed a local recurrence, while no one experienced an isolated pelvic lymph node (PLN) recurrence. In the outside RT field group, the most frequent site of recurrence was lung (60%), and three-quarters of patients were free from intra-RT field recurrence until the last follow-up. Of the entire cohort, including 48 PLN-positive patients, only seven patients (5.1%) developed PLN persistence or recurrence, all in the common iliac, internal iliac, and/or obturator nodes, and all with another synchronous relapse. Conclusion Local disease was a major type of intra-RT field recurrence, while PLN control was favorable even in initially PLN-positive patients. The predominance of outside RT field recurrence alone highlights issues concerning distant control, including the intensity enhancement of systematic therapy.
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Affiliation(s)
- Reiko Kobayashi
- Department of Radiology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hideomi Yamashita
- Department of Radiology, University of Tokyo Graduate School of Medicine, Tokyo, Japan.
| | - Kae Okuma
- Department of Radiology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kuni Ohtomo
- Department of Radiology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
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25
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Jena R. Cervical Cancer Virtual Special Issue. Clin Oncol (R Coll Radiol) 2015; 27:431-2. [PMID: 26089121 DOI: 10.1016/j.clon.2015.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 05/12/2015] [Indexed: 10/23/2022]
Affiliation(s)
- R Jena
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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