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Sarwar A, Eminowicz G. Radiotherapy induced ureteric stenosis in locally advanced cervical cancer: A review of current evidence. Brachytherapy 2024:S1538-4721(24)00044-8. [PMID: 38643044 DOI: 10.1016/j.brachy.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/25/2024] [Accepted: 03/13/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Concurrent chemo-radiation followed by high dose rate brachytherapy is the standard of care for locally advanced cervical cancer. The proximity of the ureters to the tumor volume risks ureteric stenosis. Here we outline the current understanding of radiotherapy induced ureteric stenosis in patients treated for cervical cancer, focusing on the incidence, risk factors, clinical consequences, and management. METHODS Searches on EMBASE, PubMed, Science Direct, and Google Scholar were performed for publications reporting on radiotherapy, cervix cancer and ureteric stenosis. Multi and single center, prospective/retrospective, cohort, and cross-sectional studies were included. RESULTS This narrative review identified key issues relevant to radiation induced ureteric stenosis in cervical cancer in the literature. Thirteen studies were evaluated, identifying crude and actuarial rates of ureteric stenosis of 0.3-13.5% and 1.5-4.4% (at 5 years) respectively. The risk of ureteric stenosis is highest in the first 5 years after radiotherapy but continues to occur at a rate of 0.15% per year. Risk factors including advanced FIGO stage, tumor size >5 cm and baseline hydronephrosis increase the incidence of ureteric stenosis. EQD2 doses of ≥ 77Gy were significantly associated with ≥grade 3 ureteric morbidity. The majority of patients were managed with nephrostomy +/- ureteric stent insertion, with some requiring ureteral reimplantation, urinary diversion or nephrectomy. CONCLUSIONS This review has identified multiple considerations, highlighting the need to identify patients highest at risk of ureteric stenosis. There is also a need to recognize ureters as organs at risk, record dose exposure, and apply dose constraints, all of which set the landscape for allowing dose optimization.
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Affiliation(s)
- Asma Sarwar
- University College London Hospitals, London, UK; University College London, London, UK.
| | - Gemma Eminowicz
- University College London Hospitals, London, UK; University College London, London, UK
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Malikova H, Nadova K, Reginacova K, Kremenova K, Rob L. Radiation-Related Fractures after Radical Radiotherapy for Cervical and Endometrial Cancers: Are There Any Differences? Diagnostics (Basel) 2024; 14:810. [PMID: 38667456 PMCID: PMC11049002 DOI: 10.3390/diagnostics14080810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
In this study, we reviewed CT/MRI scans and studied the rates of radiation-related fractures in subjects treated for cervical cancer (CC, 63 subjects) by radical radiotherapy (RT) and in subjects treated for endometrial cancer (EC, 64 subjects) by radical surgery and RT. The differences between bone density measured in L1 on pretreatment CT, age and body mass index (BMI) were evaluated. Despite significant differences in RT total dose, age, BMI, etc., between both groups, the rate of radiation-related fractures was similar: 28.6% of CC versus 26.6% of EC subjects. CC subjects with fractures were significantly older (62.4 ± 10.1 vs. 49.0 ± 12.4 years; p < 0.001), and their bone densities were significantly lower (106.3 ± 40.0 vs. 168.2 ± 49.5 HU; p < 0.001); no difference in BMI was found. EC subjects with fractures were without significant difference in age but had significantly lower bone densities (103.8 ± 29.0 vs. 133.8 ± 42.3 HU; p = 0.009) and BMIs (26.1 ± 4.9 vs. 31.8 ± 6.9 kg/m2; p = 0.003). Bone density strongly correlated with age (r = -0.755) only in CC subjects. Subjects with fractures from both groups had similarly low bone densities (106.3 ± 40.0 vs. 103.8 ± 29.0 HU; p = 0.829); however, no correlation between bone density and BMI was found. The rate of radiation-related fractures in both groups was clearly associated only with low pretreatment bone density, reflecting osteoporosis.
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Affiliation(s)
- Hana Malikova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (K.N.); (K.K.)
- Institute of Anatomy, Second Faculty of Medicine, Charles University, 11000 Prague, Czech Republic
| | - Katarina Nadova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (K.N.); (K.K.)
- Institute of Anatomy, Second Faculty of Medicine, Charles University, 11000 Prague, Czech Republic
| | - Klaudia Reginacova
- Department of Oncology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic;
| | - Karin Kremenova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (K.N.); (K.K.)
| | - Lukas Rob
- Department of Obstetrics and Gynaecology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic;
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Palagudi M, Para S, Golla N, Meduri KC, Duvvuri SP, Vityala Y, Sajja DC, Damineni U. Adverse Effects of Cancer Treatment in Patients With Cervical Cancer. Cureus 2024; 16:e54106. [PMID: 38487144 PMCID: PMC10938271 DOI: 10.7759/cureus.54106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND In lower- to middle-income countries such as India, the literature on the adverse effects (AEs) of cancer treatment in patients with cervical cancer is very limited. This knowledge gap provides an opportunity to investigate and improve the quality of life for women with cervical cancer. OBJECTIVE The purpose of this study was to assess the AEs of various cancer treatment combinations in patients with cervical cancer. METHODS This observational, retrospective study analysed 1,030 women with cervical cancer, with a descriptive cross-sectional design, based on a review of medical records from patients who were followed up during the morbidity consultation conducted by a multidisciplinary team of doctors. The AEs of cancer treatment for women with cervical cancer were recorded in these medical records between October 14, 2019, and November 21, 2022, at 10 major public tertiary hospitals in India. RESULTS This study analysed 1,030 women with cervical cancer aged between 21 and 80 years (mean age: 48.8 ± 13.9 years; p=0.30). Patients between the ages of 36-50 years reported the most AEs (30.2%; 95% confidence interval (CI): 29.1-32.8) among other age groups. Combined radiation therapy and chemotherapy (CT) was the type of cancer treatment in which there were more AEs, presenting in 56.0% (95% CI: 55-60.1) of patients. Adverse effects associated with the gastrointestinal system were observed in the majority (92.5%, 95% CI: 90.2-96.9) of cervical cancer patients. CONCLUSION Exposure to different cancer treatments, particularly combination therapy, induces AEs in patients during and after cervical cancer treatment.
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Affiliation(s)
- Mahesh Palagudi
- Department of General Medicine, P.E.S. Institute of Medical Sciences and Research, Kuppam, IND
| | - Sneha Para
- Department of General Medicine, Maheshwara Medical College and Hospital, Hyderabad, IND
| | - Nagasree Golla
- Department of General Medicine, I. K. Akhunbaev Kyrgyz State Medical Academy, Bishkek, KGZ
| | | | - Sai Praneeth Duvvuri
- Department of General Medicine, Maheshwara Medical College and Hospital, Hyderabad, IND
| | - Yethindra Vityala
- Department of Research, AJ Research Centre, AJ Institute of Medical Sciences and Research Centre, Mangalore, IND
- Department of Pathology, International Higher School of Medicine, International University of Kyrgyzstan, Bishkek, KGZ
| | | | - Ujwala Damineni
- Department of General Medicine, Maheshwara Medical College and Hospital, Hyderabad, IND
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Wu J, Lakomy DS, Fellman BM, Salcedo MP, Sood AK, Jhingran A, Klopp AH, Iyer RB, Jimenez C, Colbert LE, Eifel PJ, Schmeler KM, Lin LL. Longitudinal Changes in Bone Mineral Measurements Inside and Outside Radiation Fields Used for Cervical Cancer Treatment. Pract Radiat Oncol 2022; 12:e423-e433. [PMID: 35390531 DOI: 10.1016/j.prro.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/18/2022] [Accepted: 03/31/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE We compared the magnitude of changes in bone mineral density (BMD), within and outside the radiation field, among women who received pelvic radiotherapy (RT) with or without chemotherapy for cervical cancer. PATIENTS & METHODS In this secondary analysis of a prospective study, we analyzed serial CT scans and dual-energy X-ray absorptiometry (DXA) scans from 78 patients who received definitive RT or chemoradiation (CRT) for cervical cancer at a single institution from 2008 to 2015. BMD values at L1, L2, L3 and L4 were measured. We compared changes in BMD within the radiation field (i.e., at L4) with those outside the field (i.e., at L1). Linear mixed models were also used to examine the effect of RT on changes in BMD over time and covariate adjustment. RESULTS The median age of the 78 patients was 45.5 years (range 23-88); all received RT and 76 (97%) received concurrent CRT. Treatment was associated with significant declines in BMD in all 4 lumbar vertebral bodies over time (P<0.05), with nadir at 3 months for L4 and at 1 year for L1. Pairwise comparisons at 3 months and 2 years after treatment indicated that BMD in L4 (within the RT field) had improved (P=0.037), but BMD in L1 (outside the RT field) was no different at 3 months and 2 years. CONCLUSIONS Significant BMD declines were observed in all lumbar vertebral bodies immediately following RT. However, in-field vertebral bodies reached nadir BMD earlier than those located outside the RT field. Our results suggest that treatment and patient-related factors other than RT may contribute to declines in BMD after treatment for cervical cancer. Routine bone density screening and post-RT therapy with hormones may be beneficial for selected patients who receive CRT for cervical cancer.
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Affiliation(s)
- Juliana Wu
- University of Texas Medical Branch, Galveston, TX; Departments of Radiation Oncology, Houston, TX
| | - David S Lakomy
- Departments of Radiation Oncology, Houston, TX; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Mila P Salcedo
- Departments of Gynecologic Oncology and Reproductive Medicine, Houston, TX; Obstetrics and Gynecology Department, Federal University of Health Sciences/Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil
| | - Anil K Sood
- Departments of Gynecologic Oncology and Reproductive Medicine, Houston, TX
| | | | - Ann H Klopp
- Departments of Radiation Oncology, Houston, TX
| | | | - Camilo Jimenez
- Departments of Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Lilie L Lin
- Departments of Radiation Oncology, Houston, TX.
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Malikova H, Burghardtova M, Fejfarova K, Nadova K, Weichet J. Advanced cervical cancer in young women: imaging study of late and very late radiation-related side effects after successful treatment by combined radiotherapy. Quant Imaging Med Surg 2021; 11:21-31. [PMID: 33392008 DOI: 10.21037/qims-20-553] [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] [Indexed: 12/11/2022]
Abstract
Background Radical combined radiotherapy (RT) is a standard treatment for advanced cervical cancer. The aim of our study was to identify morphological late (≥6 months) and very late (≥5 years) radiation-related comorbidities on computed tomography (CT), positron emission tomography/computerized tomography (PET/CT) or magnetic resonance imaging (MRI) scans in young females who survived ≥5 years since RT and were considered as successfully treated. Secondly, we studied a rate of clinically silent radiation-related toxicities apparent on imaging scans that might influenced on future well-being of survived females. Thirdly, we analyzed reasons why patients underwent imaging scans. Methods We included 41 subjects aged under 50 years (mean 41.8±7.2 years, median 41 years), who survived ≥5 years since RT, with at least one available imaging scan ≥3 years since RT. The mean time between RT and the last available scan was 12.3±7.9 years (median 9 years); the mean time of clinical follow-up was 15.4±7.1 years (median 14 years). Results Fourteen (34.1%) females underwent the first imaging scan in emergency situation and 27 (65.9%) patients due to variable chronic complaints. Grade III-V radiation-related comorbidities occurred in 19 (46.3%) females including one case of death due to radiation-induced osteosarcoma. In 14 of 19 patients, comorbidities were multiple. Four (9.8%) females suffered from life-threatening complications (grade IV): one from an uretero-arterial fistula with massive hematuria and 3 from bowel perforations. Eleven (26.8%) subjects suffered from bowel strictures with ileus development, they underwent mean 1.7±0.8 surgery (median 1.5). The mean time since RT to the first surgery for intestinal complications was 5.4±6.0 years (median 3 years), to the second 12.0±9.6 years (median 11.5 years) and to the third surgery 9.0±4.2 years (median 9 years). Late fistulas formations (vesico-recto-vaginal) were seen in 6 (14.6%) patients. Bone complications were diagnosed in 9 (22.0%) of treated females, one case of osteosarcoma included, 4 of 9 bone complications were clinically silent. In 5 (12.2%) subjects, toxicities grade III-IV first time manifested >5 years since RT, majority of them were multiple. The bowel perforation and fistulas formations were the earliest manifested grade III-IV toxicities, with median time 3 years since RT, the bone complications were the latest manifested with median time 16 years since RT. Conclusions Our study is not able to bring information about the incidence of late and very late radiation related comorbidities, according to International Federation of Gynecology and Obstetrics (FIGO) recommendations patients are clinically followed only for 5 years and imaging cross-sectional scans are not recommended. However, our study shows that if females successfully treated for advanced cervical cancer report abdominal/pelvic clinical problems, it is highly probable their imaging scans will reveal late radiation related side-effects that may affect the rest of their life. It puts forward question whether females after radical RT should been regularly followed by cross-sectional imaging methods.
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Affiliation(s)
- Hana Malikova
- Radiology Department, Third Faculty of Medicine, Faculty Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic.,Institute of Anatomy, Second Medical Faculty, Charles University, Prague, Czech Republic
| | - Miroslava Burghardtova
- Radiology Department, Third Faculty of Medicine, Faculty Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Klara Fejfarova
- Radiology Department, Third Faculty of Medicine, Faculty Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Katarina Nadova
- Radiology Department, Third Faculty of Medicine, Faculty Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Jiri Weichet
- Radiology Department, Third Faculty of Medicine, Faculty Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
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Sequencing of Adjuvant Chemoradiation for Advanced Stage Endometrial Cancer. Am J Clin Oncol 2020; 43:755-761. [DOI: 10.1097/coc.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Radiation-Induced Insufficiency Fractures After Pelvic Irradiation for Gynecologic Malignancies: A Systematic Review. Int J Radiat Oncol Biol Phys 2020; 108:620-634. [DOI: 10.1016/j.ijrobp.2020.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/15/2022]
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Salcedo MP, Sood AK, Jhingran A, Eifel PJ, Klopp AH, Iyer RB, Fellman BM, Jimenez C, Schmeler KM. Pelvic fractures and changes in bone mineral density after radiotherapy for cervical, endometrial, and vaginal cancer: A prospective study of 239 women. Cancer 2020; 126:2607-2613. [PMID: 32125711 DOI: 10.1002/cncr.32807] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advances in radiotherapy (RT) have led to improved oncologic outcomes for women with gynecologic cancers; however, the long-term effects and survivorship implications need further evaluation. The purpose of this study was to determine the incidence of pelvic fractures and changes in bone mineral density (BMD) after pelvic RT. METHODS Two hundred thirty-nine women who had pelvic RT for cervical, endometrial, or vaginal cancer between 2008 and 2015 were prospectively studied. BMD scans and biomarkers of bone turnover were obtained at the baseline and 3 months, 1 year, and 2 years after RT. Imaging studies were assessed for pelvic fractures for up to 5 years. Patients with osteopenia, osteoporosis, or pelvic fractures at any point were referred to the endocrinology service for evaluation and treatment. RESULTS The median age at diagnosis was 51 years; 132 patients (56%) were menopausal. The primary diagnoses were cervical (63.6%), endometrial (30.5%), and vaginal cancer (5.9%). Sixteen patients (7.8%; 95% confidence interval, 4.5%-12.4%) had pelvic fractures with actuarial rates of 3.6%, 12.7%, and 15.7% at 1, 2, and 3 years, respectively. Fractures were associated with baseline osteoporosis (P < .001), higher baseline bone-specific alkaline phosphatase (P < .001), and older age (P = .007). The proportion of patients with osteopenia/osteoporosis increased from 50% at the baseline to 58%, 59%, and 70% at 3 months, 1 year, and 2 years, respectively. CONCLUSIONS A high proportion of women had significant decreases in BMD after pelvic RT, with 7.8% diagnosed with a pelvic fracture. BMD screening and pharmacologic intervention should be strongly considered for these high-risk women.
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Affiliation(s)
- Mila P Salcedo
- Obstetrics and Gynecology Department, Federal University of Health Sciences/Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil.,Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anil K Sood
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Revathy B Iyer
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bryan M Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Camilo Jimenez
- Department of Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Piotto C, Biscontin A, Millino C, Mognato M. Functional validation of miRNAs targeting genes of DNA double-strand break repair to radiosensitize non-small lung cancer cells. BIOCHIMICA ET BIOPHYSICA ACTA-GENE REGULATORY MECHANISMS 2018; 1861:1102-1118. [PMID: 30389599 DOI: 10.1016/j.bbagrm.2018.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 10/18/2018] [Accepted: 10/23/2018] [Indexed: 01/10/2023]
Abstract
DNA-Double strand breaks (DSBs) generated by radiation therapy represent the most efficient lesions to kill tumor cells, however, the inherent DSB repair efficiency of tumor cells can cause cellular radioresistance and impact on therapeutic outcome. Genes of DSB repair represent a target for cancer therapy since their down-regulation can impair the repair process making the cells more sensitive to radiation. In this study, we analyzed the combination of ionizing radiation (IR) along with microRNA-mediated targeting of genes involved in DSB repair to sensitize human non-small cell lung cancer (NSCLC) cells. MicroRNAs are natural occurring modulators of gene expression and therefore represent an attractive strategy to affect the expression of DSB repair genes. As possible IR-sensitizing targets genes we selected genes of homologous recombination (HR) and non-homologous end joining (NHEJ) pathway (i.e. RAD51, BRCA2, PRKDC, XRCC5, LIG1). We examined these genes to determine whether they may be real targets of selected miRNAs by functional and biological validation. The in vivo effectiveness of miRNA treatments has been examined in cells over-expressing miRNAs and treated with IR. Taken together, our results show that hsa-miR-96-5p and hsa-miR-874-3p can directly regulate the expression of target genes. When these miRNAs are combined with IR can decrease the survival of NSCLC cells to a higher extent than that exerted by radiation alone, and similarly to radiation combined with specific chemical inhibitors of HR and NHEJ repair pathway.
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Affiliation(s)
- Celeste Piotto
- Department of Biology, School of Sciences, University of Padova, via U. Bassi 58 B, 35131 Padova, Italy
| | - Alberto Biscontin
- Department of Biology, School of Sciences, University of Padova, via U. Bassi 58 B, 35131 Padova, Italy
| | - Caterina Millino
- CRIBI Biotechnology Centre, University of Padova, via U. Bassi 58/B, 35131 Padova, Italy
| | - Maddalena Mognato
- Department of Biology, School of Sciences, University of Padova, via U. Bassi 58 B, 35131 Padova, Italy.
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