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Ritzmann D. Herbal Treatment of Female Urogenital Atrophy: A Retrospective Cohort Analysis. Complement Med Res 2024; 31:124-132. [PMID: 38211573 PMCID: PMC11098024 DOI: 10.1159/000536193] [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: 11/18/2022] [Accepted: 01/08/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Urogenital atrophy and its sequelae, particularly genital dryness, urological problems, and pain on genital touching, are common medical problems for menopausal women and women undergoing antihormonal cancer treatment. To meet the requirements for a nonhormonal local treatment, a compounded herbal preparation was developed as a vaginal ovule (Dioscorea comp. ovulum), and the efficacy and applicability of this herbal treatment were investigated. METHODS This was a retrospective chart review of patients' records. The study was approved by the Ethics Committee of the Canton of Zurich (project number BASEC 2016-01982). Between 2007 and 2011, patients with urogenital atrophy and related symptoms, who wanted to initiate herbal treatment, were asked for consent to be interviewed (4-point rating scale) and examined gynecologically with photo documentation of their vaginal discharge. A total of 26 patients met the enrollment criteria and consented to the procedure. The first 8 weeks consisted of a daily application of low-dose Dioscorea comp. ovulum followed by high-dose Dioscorea comp. ovule twice weekly for at least 3 months. RESULT A total of 23 patients completed the trial. Of the 19 patients in the subgroup with an atrophic vaginal maturation index (VMI), 16 achieved a eutrophic VMI. Four patients began therapy with hypotrophy. There was a 96% decrease in complaints (22/23). The genital dryness score decreased from 1.80 to 0.25 points, urological problems from 2.38 to 0.85 points, and pain on genital touching from 1.70 to 0.60 points. Application, tolerability, and medical safety of the formula were good. CONCLUSION The phytotherapeutic compounded preparation Dioscorea comp. ovule (Dioscorea villosa, Glycine max, Salvia officinalis) is suitable for the treatment of urogenital atrophy and its sequelae. Hintergrund Urogenitale Atrophie und ihre Folgeerscheinungen, insbesondere genitale Trockenheit, urologische Probleme und schmerzhafte genitale Berührungen, sind ein häufiges medizinisches Problem bei menopausalen Frauen und Frauen unter antihormoneller Krebstherapie. Um den Bedarf an einer nicht-hormonellen lokalen Behandlung zu decken, wurde ein pflanzliches Präparat in Form eines Vaginal-Ovulum ( Dioscorea comp. Ovulum) entwickelt. Wirksamkeit und Anwendbarkeit dieser pflanzlichen Behandlung werden untersucht. Patientinnen und Methoden Es handelt sich um eine retrospektive Analyse. Das Studienprotokoll wurde von der Ethikkommission des Kantons Zürich genehmigt (Projekt Nummer BASEC 2016-01982). Zwischen 2007 und 2011 wurden geeignete Patientinnen mit urogenitaler Atrophie und assoziierten Beschwerden, die mit einer pflanzlichen Behandlung beginnen wollten, um ihr Einverständnis zu einer Befragung (4-Punkte-Score) und gynäkologischen Untersuchungen mit Fotodokumentation des Vaginalausflusses (Nativpräparat) gebeten. 26 Patientinnen erfüllten die Kriterien und erklärten sich mit dem Verfahren einverstanden. Behandlung Nach einer täglichen Anwendung eines niederdosierten Dioscorea comp. Ovulum folgte eine zweimal wöchentliche Anwendung des höher dosierten Dioscorea comp. Ovulum für mindestens 3 Monate. Ergebnisse Insgesamt 23 Patientinnen schlossen die Studie ab. 16 von 19 Patientinnen in der Untergruppe mit einem atrophen Vaginalen Maturations-Index (VMI) erreichten ein eutrophes Vaginalepithel. Vier Patientinnen begannen mit einer Hypotrophie. Ein Rückgang der Beschwerden wurde bei 96% (22 von 23) erreicht: Trockenheit im Genitalbereich ging von 1,80 auf 0,25 Score-Punkte zurück, urologische Probleme von 2,38 auf 0,85 Score-Punkte und schmerzhafte Berührungen im Genitalbereich von 1,70 auf 0,60 Score-Punkte. Anwendung, Verträglichkeit und medizinische Sicherheit der Magistralrezeptur sind gut. Schlussfolgerung Das phytotherapeutische Kombinationspräparat Dioscorea comp. Ovulum ( Dioscorea villosa L. , Glycine Max Merr. , Salvia officinalis L.) eignet sich zur Behandlung der urogenitalen Atrophie und ihrer Folgeerscheinungen.
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Affiliation(s)
- Dorin Ritzmann
- FMH Gynecology and Obstetrics, Medizin Feminin Private Practice, Dietikon, Switzerland
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Noorian F, Abellana R, Zhang Y, Herreros A, Baltrons C, Lancellota V, Tagliaferri L, Sabater S, Torne A, Rovirosa A. Are 7.5 Gy×2 fractions more efficient than 6 Gy×3 in exclusive postoperative endometrial cancer brachytherapy? A clinical and dosimetrical analysis. Radiother Oncol 2023; 189:109909. [PMID: 37699447 DOI: 10.1016/j.radonc.2023.109909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE To compare two vaginal brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) patients considering vaginal-cuff relapses (VCR), late toxicities, dosimetry analysis and vaginal dilator use. MATERIAL AND METHODS 110 PEC patients were treated with exclusive high-dose-rate VBT using two schedules. Group-1:44-patients received 6 Gy×3fractions (September-2011-April-2014); Group-2:66-patients were treated with 7.5 Gy×2fractions with a dose limit of equivalent total doses in 2-Gy fr (EQD2(α/β=3)) of 68 Gy in the most exposed 2 cm3 of clinical target volume (CTV) (July-2015-November-2021). The dose was prescribed at 5 mm from the applicator surface. Were evaluated the overall radiation dose delivered to 90% of the CTV (D90), the CTV receiving 100% of the prescription dose (V100) and the EQD2(α/β=3) received in the most exposed 2 cm3 to dose in CTV. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum and objective LENT-SOMA criteria for late vaginal toxicity (LVT). STATISTICS Descriptive analysis, Chi-square, Student's t-tests and Kaplan and Meier method. RESULTS The median follow-up was 60 months (15.9-60). There were no VCR or late toxicities in bladder or rectum. LVT ≥ G1 appeared in 26/44 (59.1%) in Group-1 and 25/66 (37.9%) in Group-2. The mean EQD2(α/β=3) received by the most exposed 2 cm3 of CTV was 63.7 Gy ± 10.0 in Group-1 and 60.5 Gy ± 3.8 in Group-2 (p = 0.063). There were no differences in adherence to vaginal dilator use ≥9 months, overall D90 and V100. CONCLUSION Considering the lack of vaginal relapses and similar LVT over time, 7.5 Gy×2fractions seem more efficient in terms of patient comfort, workload, and cost. This is the first study using dosimetry parameters to compare effectivity of schedules. Larger series are needed to confirm the present results.
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Affiliation(s)
- Faegheh Noorian
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Rosa Abellana
- Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Yaowen Zhang
- Cancer Center, Henan Provincial People's Hospital, No.7 Weiwu Road, Zhengzhou 450003, China.
| | - Antonio Herreros
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Clara Baltrons
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain.
| | - Vallentina Lancellota
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy.
| | - Luca Tagliaferri
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy.
| | | | - Aureli Torne
- Gynecological Cancer Unit, Hospital Clinic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain.
| | - Angeles Rovirosa
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
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Kunz JN, Huang YJ, Casper AC, Suneja G, Burt LM, Jhingran A, Joyner MM, Harkenrider MM, Small W, Grant JD, Kidd EA, Boucher K, Gaffney DK. Dosimetric Evaluation of Organs at Risk From SAVE Protocol. Int J Radiat Oncol Biol Phys 2023; 117:274-280. [PMID: 37023988 DOI: 10.1016/j.ijrobp.2023.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/26/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE The objective of this work was to evaluate dosimetric characteristics to organs at risk (OARs) from short-course adjuvant vaginal cuff brachytherapy (VCB) in early endometrial cancer compared with standard of care (SOC) in a multi-institutional prospective randomized trial. METHODS AND MATERIALS SAVE (Short Course Adjuvant Vaginal Brachytherapy in Early Endometrial Cancer Compared to Standard of Care) is a prospective, phase 3, multisite randomized trial in which 108 patients requiring VCB were randomized to an experimental short-course arm (11 Gy × 2 fractions [fx] to surface) and SOC arm. Those randomized to the SOC arm were subdivided into treatment groups based on treating physician discretion as follows: 7 Gy × 3 fx to 5 mm, 5 to 5.5 Gy × 4 fx to 5 mm, and 6 Gy × 5 fx to surface. To evaluate doses to OARs of each SAVE cohort, the rectum, bladder, sigmoid, small bowel, and urethra were contoured on planning computed tomography, and doses to OARs were compared by treatment arm. Absolute doses for each OAR and from each fractionation scheme were converted to 2 Gy equivalent dose (EQD23). Each SOC arm was compared with the experimental arm separately using 1-way analysis of variance, followed by pairwise comparisons using Tukey's honestly significant difference test. RESULTS The experimental arm had significantly lower doses for rectum, bladder, sigmoid, and urethra compared with the 7 Gy × 3 and 5 to 5.5 Gy × 4 fractionation schemes; however, the experimental arm did not differ from the 6 Gy × 5 fractionation scheme. For small bowel doses, none of the SOC fractionation schemes were statistically different than the experimental. The highest EQD23 doses to the examined OARs were observed to come from the most common dose fractionation scheme of 7 Gy × 3 fx. With a short median follow-up of 1 year, there have been no isolated vaginal recurrences. CONCLUSIONS Experimental short-course VCB of 11 Gy × 2 fx to the surface provides a comparable biologically effective dose to SOC courses. Experimental short-course VCB was found to reduce or be comparable to D2cc and D0.1cc EQD23 doses to rectum, bladder, sigmoid, small bowel, and urethra critical structures. This may translate into a comparable or lower rate of acute and late adverse effects.
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Affiliation(s)
- Jeremy N Kunz
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anthony C Casper
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Lindsay M Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anuja Jhingran
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Melissa M Joyner
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Center, Intermountain Health Care, Murray, Utah
| | - Elizabeth A Kidd
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Ken Boucher
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Jreij M, El Ahmar A, Finianos P. Applicators used for vaginal high dose rate brachytherapy: Effect of type and shape on dose distribution and toxicity, a literature review. Cancer Radiother 2023; 27:80-85. [PMID: 35973915 DOI: 10.1016/j.canrad.2021.10.013] [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: 05/12/2021] [Accepted: 10/26/2021] [Indexed: 02/06/2023]
Abstract
The aim of this article is to represent a literature review on the applicators used for vaginal high dose rate brachytherapy for patients with endometrial cancer. The different types and shapes of the clinically used applicator as well as the effects of their characteristics on dose distribution, target coverage and dose received by organs at risk are discussed in detail.
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Affiliation(s)
- Mirna Jreij
- American University of Science and Technology, Beirut, Lebanon.
| | - Ali El Ahmar
- American University of Science and Technology, Beirut, Lebanon
| | - Pascal Finianos
- American University of Science and Technology, Beirut, Lebanon
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Lucia F, Miranda O, Schick U, Bourbonne V, Duvergé L. Dose escalation by brachytherapy for gynecological cancers. Cancer Radiother 2022; 26:905-910. [DOI: 10.1016/j.canrad.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022]
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Parsons MW, Huang YJ, Burt L, Suneja G, Gaffney D. Vaginal cuff brachytherapy for endometrial cancer: a review of major clinical trials with a focus on fractionation. Int J Gynecol Cancer 2022; 32:311-315. [DOI: 10.1136/ijgc-2021-002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/03/2022] Open
Abstract
The use of vaginal cuff brachytherapy in the adjuvant management of endometrial cancer has increased over time. Recommendations from the American Brachytherapy Society, American Society of Radiation Oncology, and European Society for Medical Oncology help to guide the application of vaginal cuff brachytherapy. However, wide variation in practice remains regarding treatment techniques. This article reviews the use of vaginal cuff brachytherapy in the post-operative management of endometrial cancer. It covers risk stratification, treatment rationale, outcomes, and treatment planning recommendations with a specific focus on dose-fractionation regimens. The authors performed a thorough literature review of articles pertinent to the goals of this review. Also presented are early results of the Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared with Standard of Care (SAVE) trial of a two-fraction vaginal cuff brachytherapy regimen.Adjuvant vaginal cuff brachytherapy for early-stage endometrial cancer results in excellent disease control with minimal toxicity. The PORTEC-2 trial showed that vaginal cuff brachytherapy is non-inferior to external beam radiation for vaginal recurrence in patients at high-intermediate risk. Vaginal cuff brachytherapy may also be used as a boost following external beam radiation in combination with chemotherapy for high-risk histologies. Numerous techniques can be used for vaginal cuff brachytherapy, including various medical devices, dose-fractionation schedules, and treatment planning approaches. The early control results of the SAVE trial are promising and we are hopeful that this trial establishes two fraction regimens as a viable option for vaginal cuff brachytherapy.
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Lancellotta V, Macchia G, Dinapoli N, Autorino R, Campitelli M, Nardangeli A, Salvati A, Fionda B, Casà C, Cornacchione P, Rovirosa A, Kovács G, Morganti AG, Ferrandina MG, Gambacorta MA, Tagliaferri L. EROS 2.0 study: evaluation of two interventional radiotherapy (brachytherapy) schedules for endometrial cancer: a comparison of late vaginal toxicity rates. LA RADIOLOGIA MEDICA 2022; 127:341-348. [PMID: 35092552 PMCID: PMC8960610 DOI: 10.1007/s11547-022-01455-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/03/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND To compare the late toxicity rates after two different high dose rate (HDR) adjuvant intravaginal interventional radiotherapy (IRT-brachytherapy) dose schedules in stage I-II endometrial cancer. METHODS Stage I-II patients with endometrial cancer treated with surgery (with or without lymphadenectomy) and adjuvant HDR-IRT between 2014 and 2020 were included in this analysis. Patients were treated with two schedules. In the first cohort (C1), 21 Gy were delivered in three weekly fractions (7 Gy) prescribed 0.5 cm from the applicator surface. In the second cohort (C2), 24 Gy were delivered in four weekly fractions (6 Gy). The clinical target volume was the upper third of the vagina for C1 and the upper 3 cm for C2. HDR-IRT technique and point prescription (5 mm depth from the applicator surface) were the same for all patients. Vaginal toxicity was scored according to the CTCAE 5.0 scale in terms of the presence versus absence of any toxicity grade. The correlation among toxicity and clinical covariates (age, lymphadenectomy, fractionation, stage) was tested by Pearson correlation test (univariate) and by logistic regression (multivariable). RESULTS 114 stage I and three stage II patients, median age 62 (range: 32-85) years, were included in this analysis. The mean follow-up was 56.3 months in C1 (40-76) and 20 months in C2 (8-42). Vaginal late toxicity was recorded in 40 and 15 patients in C1 and 2, respectively. Age, lymphadenectomy, and fractionation were significantly correlated with toxicity at univariate analysis (p value = 0.029, 0.006, and 0.002, respectively), while stepwise logistic regression confirmed only age and fractionation as significantly correlated parameters (p value = 0.02 and 0.001, respectively). Three-year local relapse-free, distant metastasis-free and cause-specific survival rates were 96.6%, 94.8%, and 99.1%, respectively. CONCLUSIONS This analysis showed lower vaginal late toxicity rate in C2 compared to C1.
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Affiliation(s)
- Valentina Lancellotta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Gabriella Macchia
- Gemelli Molise Hospital, Radiation Oncology Unit, Università Cattolica del Sacro Cuore, 86100, Campobasso, Italy.
| | - Nicola Dinapoli
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Rosa Autorino
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Maura Campitelli
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Alessia Nardangeli
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Alessandra Salvati
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Bruno Fionda
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Calogero Casà
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Patrizia Cornacchione
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Angeles Rovirosa
- Department of Radiation Oncology, Hospital Clinic i Universitari, Fonaments Clinics Department, University of Barcelona, 08036, Barcelona, Spain
| | - György Kovács
- Università Cattolica del Sacro Cuore, 00128, Roma, Italy
| | - Alessio Giuseppe Morganti
- Radiotherapy Center, IRCCS Azienda Ospedaliera Universitaria di Bologna, 40138, Bologna, Italy
- DIMES, Alma Mater Studiorum University of Bologna, 40138, Bologna, Italy
| | - Maria Gabriella Ferrandina
- Woman, Child and Public Health Department, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, Roma, Italy
| | - Maria Antonietta Gambacorta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, 00128, Rome, Italy
| | - Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
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Barcellini A, Dominoni M, Dal Mas F, Biancuzzi H, Venturini SC, Gardella B, Orlandi E, Bø K. Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training. Front Med (Lausanne) 2022; 8:813352. [PMID: 35186978 PMCID: PMC8852813 DOI: 10.3389/fmed.2021.813352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction The present study aims to describe: 1. How the side effects of radiotherapy (RT) could impact sexual health in women; 2. The effectiveness of physical rehabilitation including pelvic floor muscle training (PFMT) in the management of sexual dysfunction after RT. Materials and Methods Search keys on PubMed, Web of Science, Scopus, PEDro, and Cochrane were used to identify studies on women treated with radical or adjuvant RT and/or brachytherapy for gynecological cancers with an emphasis on vulvo-vaginal toxicities and PFMT studies on sexual dysfunction for this group of women. Results Regarding the first key question, we analyzed 19 studies including a total of 2,739 women who reported vaginal dryness, stenosis, and pain as the most common side effects. Reports of dosimetric risk factors and dose-effect data for vaginal and vulvar post-RT toxicities are scant. Only five studies, including three randomized controlled trials (RCTs), were found to report the effect of PFMT alone or in combination with other treatments. The results showed some evidence for the effect of training modalities including PFMT, but to date, there is insufficient evidence from high-quality studies to draw any conclusion of a possible effect. Conclusions Gynecological toxicities after RT are common, and their management is challenging. The few data available for a rehabilitative approach on post-actinic vulvo-vaginal side effects are encouraging. Large and well-designed RCTs with the long-term follow-up that investigate the effect of PFMT on vulvo-vaginal tissues and pelvic floor muscle function are needed to provide further guidance for clinical management.
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Affiliation(s)
- Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
- *Correspondence: Amelia Barcellini
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Dal Mas
- Lincoln International Business School, University of Lincoln, Lincoln, United Kingdom
- Center of Organization and Governance of the Public Administration, University of Pavia, Pavia, Italy
| | - Helena Biancuzzi
- Ipazia, International Observatory on Gender Research, Rome, Italy
| | | | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Kari Bø
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lorenskog, Norway
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Nieto K, Levine B, Brown D, Lanier C, Carriere P, McGinnis H, Hines K, Greven K. Pilot study to assess sexual function, quality of life (QOL) and change in vaginal dimensions following vaginal brachytherapy (VBT). Brachytherapy 2022; 21:283-290. [DOI: 10.1016/j.brachy.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/02/2022]
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Arden JD, Dokter J, Almahariq MF, Marvin K, Nandalur SR, Al-Wahab Z, Gadzinski J, Rosen B, Jawad MS. Toxicity and Efficacy After Adjuvant Vaginal Brachytherapy Using 30 Gy in 6 Fractions for Stages I and II Endometrial Cancer. Adv Radiat Oncol 2021; 6:100773. [PMID: 34934859 PMCID: PMC8655421 DOI: 10.1016/j.adro.2021.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose This study aimed to evaluate outcomes and toxicity in patients with endometrial cancer per our institutional adjuvant vaginal cuff brachytherapy (VBT) fractionation scheme. Methods and Materials We identified women with International Federation of Gynecology and Oncology stages I and II endometrial cancer who underwent surgical staging and adjuvant high-dose-rate VBT without external beam radiation. All patients received 30 Gy in 6 fractions to the upper one-third of the vagina, prescribed to a depth of 5 mm and delivered twice weekly. Toxicities were prospectively elicited at each follow up, and rates of recurrence and survival were retrospectively assessed. Results We identified 247 eligible patients treated between 1992 and 2018 with a median follow up of 5.8 years (range, 0.1-24.7 years). Most patients had stage I disease (52% stage IA; 37% stage IB), and 11% of patients were stage II. Deep myometrial invasion was predictive of local recurrence (P = .002). The 5-year rates of local recurrence, regional recurrence, and distant metastases were 5%, 5%, and 7%, respectively. Five-year overall and disease-free survival were 91% and 83%, respectively. The most common grade 1 toxicities were acute fatigue (11% crude rate), urinary frequency (11%), chronic (>6 months) urinary frequency (13%), urinary incontinence (13%), and vaginal stenosis (21%). There were few grade 2 toxicities (all <5%) and no grade 3 to 5 toxicities. Conclusions The adjuvant VBT fractionation scheme of 30 Gy in 6 fractions results in low rates of toxicity, with no grade ≥3 adverse events, and local control rates comparable with those from other published series using different fractionation schemes.
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Affiliation(s)
- Jessica D Arden
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jonathan Dokter
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kimberly Marvin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sirisha R Nandalur
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid Al-Wahab
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jill Gadzinski
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Barry Rosen
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Maha Saada Jawad
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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Pelvic Radiation Therapy Induced Vaginal Stenosis: A Review of Current Modalities and Recent Treatment Advances. ACTA ACUST UNITED AC 2021; 57:medicina57040336. [PMID: 33915994 PMCID: PMC8066324 DOI: 10.3390/medicina57040336] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022]
Abstract
Radiation-induced vaginal stenosis (VS) is a common side effect of pelvic radiotherapy (RT). RT-induced VS may have various negative effects on women’s quality of life, in particular dyspareunia, decreased vaginal lubrication and difficulties in sexual intercourse. This narrative review provides the aspects of RT-induced VS pathogenesis, incidence, evaluation and associated risk factors. Available treatment modalities are discussed in the article, putting the focus on preliminary, although promising, experience in the use of hyaluronic acid and laser therapy in cancer survivors after pelvic RT.
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12
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Do air gaps with image-guided vaginal cuff brachytherapy impact failure rates in patients with high-intermediate risk FIGO Stage I endometrial cancer? Brachytherapy 2020; 20:512-518. [PMID: 33384254 DOI: 10.1016/j.brachy.2020.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/20/2020] [Accepted: 11/20/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this study was to assess the impact of air gaps at the cylinder surface on the rate of vaginal cuff failure (VCF) after image-guided adjuvant vaginal cuff brachytherapy (VCBT) in the treatment of high-intermediate risk (HIR) FIGO (Fédération Internationale de Gynécologie et d'Obstétrique (International Federation of Gynecology and Obstetrics)) Stage I endometrial cancer. METHODS AND MATERIALS A retrospective review of patients treated with image-guided VCBT from 2009 to 2016 for HIR FIGO Stage I endometrial cancer was performed. Air gaps present at the applicator surface on the first postinsertion CT were contoured. Vaginal cuff failure-free survival (VCFFS) was measured from the first fraction of VCBT to VCF. RESULTS A total of 234 patients were identified. Air gaps were present on the first postinsertion CT scan in 82% of patients. The median number of air gaps was 2 (interquartile range [IQR] 1-3), median depth of the largest air gap was 2.7 mm (IQR 2.1-3.4 mm), and the median cumulative volume of air gaps was less than 0.1 cm3 (range < 0.1-0.7 cm3). At a median followup of 56 months (IQR 41-69), 12 patients (5%) experienced VCF, of which 4 had isolated VCF and 8 had synchronous pelvic or distant failure. Five-year VCFFS and isolated VCFFS were 96% (95% confidence interval 93-98%) and 98% (95% confidence interval 96-100%), respectively. On univariate analysis, no factors, including the presence, number, maximum depth, or cumulative volume of air gaps, were predictive for VCFFS. CONCLUSIONS In this population, VCFFS remained high despite most patients having air gaps present on postinsertion CT scan.
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Song J, Le T, Hopkins L, Fung-Kee-Fung M, Jooya A, Lupe K, Gaudet M, Samant R. Treatment of Early Stage High-Risk Endometrioid-Type Endometrial Cancer and Patterns of Disease Relapse: A Retrospective Analysis. Adv Radiat Oncol 2020; 5:910-919. [PMID: 33083653 PMCID: PMC7557164 DOI: 10.1016/j.adro.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/29/2020] [Accepted: 07/15/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose A recently published randomized controlled trial has demonstrated that in patients with endometrial cancer with high-risk features, the addition of chemotherapy to radiation therapy, compared with radiation therapy alone, resulted in a significant improvement in failure-free survival. However, in the study, the effect of chemotherapy was limited to stage III patients, and the benefit was less pronounced in stage I and II patients. Our study aims to investigate the current practice of treatment and clinical outcomes in stage I high-risk endometrioid-type endometrial cancer. Methods and Materials A single-center retrospective study was conducted on patients with stage I high-risk endometrioid-type endometrial cancer without serous or clear cell features who have undergone hysterectomy between 1998 and 2015. Data on patients, tumor, and treatments were collected and correlated with clinical outcomes. Results A total of 1,572 patients with stage I disease were identified and 46 patients who met the inclusion criteria were selected for final analysis. The median age at diagnosis was 63 years (range, 49-86 years) and median follow-up was 5.9 years. Among the entire cohort, 40 (87.0%) patients underwent adjuvant radiation therapy, of which 36 (78.2%) patients underwent external beam radiation therapy and 4 (8.7%) patients underwent vaginal brachytherapy. Two of the 40 patients who received adjuvant radiation therapy also received adjuvant chemotherapy. Six (13.0%) patients received no adjuvant treatment. Of the 46 patients, the cumulative risk of distant recurrence was 19.6%, and only 1 patient (2.2%) recurred within pelvis (perirectal lymph node). Five-year disease-free survival and overall survival rates were 73.1% and 80.1%, respectively. Conclusions Adjuvant radiation therapy in stage I endometrioid-type endometrial cancer patients with high-risk features resulted in high rates of locoregional disease control, and most recurrences occurred at distant sites. Effective systemic therapy may be indicated in this patient population to further reduce the risk of distant relapses and improve survival.
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Affiliation(s)
- Jiheon Song
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Tien Le
- Division of Gynecologic Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Laura Hopkins
- Division of Gynecologic Oncology, Saskatoon Cancer Center, Saskatoon, SK, Canada
| | | | - Alborz Jooya
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Krystine Lupe
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Gaudet
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Rajiv Samant
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
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Sarria GR, Sperk E, Wenz F, Schneider F, Abo-Madyan Y, Giordano FA, Ehmann M. Adjuvant electronic brachytherapy for endometrial carcinoma: A 4-year outcomes report. Brachytherapy 2020; 19:635-641. [PMID: 32651094 DOI: 10.1016/j.brachy.2020.06.002] [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: 03/31/2020] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of the study was to report the outcomes of a single-center adjuvant electronic brachytherapy (e-BT) experience for patients with endometrial carcinoma. METHODS AND MATERIALS Patients were retrospectively assessed. Intracavitary e-BT was applied through a cylindrical applicator (diameters 2.5-3.5 cm). e-BT single doses ranged between 4 and 7 Gy (EQD2 ∼ 6-12, α/β of 10 Gy and an relative biological effectiveness of 1.3) at 5-mm depth. Adverse events are reported at first week, 1-3 months, 3-12 months, 12-24 months, and >24 months. The overall survival, disease-free survival, distant disease control rate, and local control rate were estimated using the Kaplan-Meier method. RESULTS Twenty-nine patients were assessed. The median age was 68 [48-86] years. External beam radiotherapy was added in n = 8 (27.6%) patients. Staging was 13.8% for T1a, 51.7% for T1b, 24.1% for T2, 6.9% for T3a, and 3.4% for T3b. Grading was G3 in 51.7% (n = 15), G2 in 20.7% (n = 6), and G1 in 27.6% (n = 8). Median followup was 47 months [5-88]. Overall Grade 1, 2, and 3 toxicity was 89.7% (n = 26), 17.2% (n = 5), and 6.9% (n = 2), respectively. No Grade 3 cystitis or proctitis or any Grade 4 or 5 toxicity occurred during followup. No local recurrences were detected. Estimated distant disease control rate was 92.1% (n = 2, distant metastasis at 7 and 11 months). Estimated 4-year overall survival was 84.8% (n = 4 events, two unrelated to disease) and disease-free survival was 84.6%. CONCLUSIONS Our data suggest that e-BT resembles a very-low-toxicity profile and a high local control rate in the adjuvant scenario for patients with endometrial carcinoma.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, Medical Faculty Freiburg, Freiburg University, Freiburg, Germany
| | - Frank Schneider
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany.
| | - Michael Ehmann
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Time-driven activity-based costing of adjuvant vaginal cuff brachytherapy for uterine cancer in an integrated brachytherapy suite. Brachytherapy 2020; 19:176-180. [DOI: 10.1016/j.brachy.2019.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 11/19/2022]
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Zhang Y, Ascaso C, Herreros A, Sánchez J, Sabater S, Pino MD, Li Y, Gómez G, Torné A, Biete A, Rovirosa Á. Postoperative endometrial carcinoma treated with external beam irradiation plus vaginal-cuff brachytherapy. Is there a dose relationship with G2 vaginal complications? Rep Pract Oncol Radiother 2020; 25:227-232. [PMID: 32042274 PMCID: PMC7000548 DOI: 10.1016/j.rpor.2020.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/10/2020] [Indexed: 01/26/2023] Open
Abstract
AIM To analyse the possible relationship between the EQD2(α/β=3Gy) at 2 cm3 of the vagina and late toxicity in vaginal-cuff-brachytherapy (VBT) after external-beam-irradiation (EBRT) for postoperative endometrial carcinoma (EC). MATERIALS AND METHODS From 2014 to 2016, 62 postoperative EC patients were treated with EBRT + VBT. The median EBRT dose was 45 Gy (44 Gy-50.4 Gy). VBT involved a single 7 Gy dose. Toxicity was prospectively evaluated using the RTOG score for the rectum and bladder and the objective LENT-SOMA criteria for the vagina. EQD2(α/β = 3Gy) at 2 cm3 of the most exposed part of the vagina was calculated by the sum of the EBRT + VBT dose. Statistics: Boxplot, Student's t and Chi-square tests and ROC curves. RESULTS Mean follow-up: 39.2 months (15-68). Late toxicity: bladder:0 patient; rectum:2 patients-G1; Vagina: 26 patients-17G1, 9G2; median EQD2(α/β=3Gy) at 2 cm3 in G0-G1 patients was 70.4 Gy(SD2.36), being 72.5 Gy(SD2.94) for G2p. The boxplot suggested a cut-point identifying the absence of G2: 100 % of G2p received >68 Gy, ROC curves showed an area under the curve of 0.72 (sensitivity of 1 and specificity of 0.15). CONCLUSIONS Doses >68 Gy EQD2(α/β=3Gy) at 2 cm3 to the most exposed area of the vagina were associated with late G2 vaginal toxicity in postoperative EC patients treated with EBRT + VBT suggesting a very good dose limit to eliminate the risk of G2 late toxicity. The specificity obtained indicates the need for prospective analyses.
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Affiliation(s)
- Yaowen Zhang
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Carlos Ascaso
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
| | - Antonio Herreros
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Joan Sánchez
- Economics Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Sebastia Sabater
- Radiation Oncology Dpt. Hospital General Universitario de Albacete, 02006 Albacete, Spain
| | - Marta del Pino
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
| | - Yan Li
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Gabriela Gómez
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
- Radiation Oncology Dpt. Instituto Nacional de Cancerología, Ciudad de México, Mexico
| | - Aureli Torné
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
| | - Albert Biete
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
| | - Ángeles Rovirosa
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
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Outcomes of intermediate-risk to high-risk stage I endometrial cancer: 10-year clinical experiences of using in-house multi-channel applicators in a single center. Chin Med J (Engl) 2020; 132:1935-1941. [PMID: 31365429 PMCID: PMC6708688 DOI: 10.1097/cm9.0000000000000382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are only very few reports on clinical outcomes using multi-channel applicators (MCA) for patients with endometrial cancer (EC) in China. We aimed to evaluate the clinical experience of treating intermediate-risk (IR) to high-risk (HR) stage I EC using in-house made multi-channel applicators (IH-MCA) in a single institution. METHODS Three hundred and ninety patients with stage I IR to HR EC were treated with hysterectomy and adjuvant radiotherapy from 2003 to 2015. All patients received post-operative vaginal cuff brachytherapy (VBT) alone or as a boost after external beam radiotherapy (EBRT). The prescriptions were 500 cGy per fraction for a total of 5 to 6 fractions with brachytherapy alone or 400 to 600 cGy per fraction for 2 to 3 fractions if it was combined with EBRT. Two types of applicators including a traditional rigid IH-MCA and a recent model custom-made with 3 dimension printing technology were used for treatment. The Kaplan-Meier method was used to calculate survival rate. RESULTS Follow-up rate was 92.8% and the median follow-up time was 48 months (range 4-172 months). The 5-year overall survival (OS), progression-free survival, local recurrence, and distant metastasis rates for all patients were 96.3%, 92.1%, 2.9%, and 4.8% respectively. Two patients had isolated relapse in vagina outside the irradiated volume. The univariate and multivariate analysis showed that age and grade were the prognostic factors correlated with OS (hazard ratio: 0.368, 95% confidence interval [CI]: 0.131-1.035, P = 0.048; hazard ratio: 0.576, 95% CI: 0.347-0.958, P = 0.026,). CONCLUSIONS For patients with IR to HR stage I EC, adjuvant VBT alone or in combination with EBRT using IH-MCA led to excellent survival and recurrence rates. Age and grade were the prognostic factors correlated with OS.
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Alban GM, Buscariollo DL, Cheng T, Pretz J, Krechmer B, Buzurovic I, Singer L, King M, Lee L. Low-Dose Adjuvant Cylinder Brachytherapy for Endometrioid Endometrial Cancer. Pract Radiat Oncol 2019; 10:95-103. [PMID: 31783169 DOI: 10.1016/j.prro.2019.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Our purpose was to evaluate outcomes and sites of failure for women with early stage endometrial adenocarcinoma treated with adjuvant high-dose-rate (HDR) vaginal brachytherapy (VB) with a low dose scheme. METHODS AND MATERIALS Retrospective review identified 318 patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrioid endometrial cancer who received adjuvant HDR VB to a dose of 24 Gray (Gy) in 6 fractions from 2005 to 2017. Patients with <6 months follow-up were excluded. Dose was prescribed to cylinder surface and computerized tomography (CT) imaging was performed before each fraction to assess cylinder placement. Rates of vaginal relapse (VR), pelvic nodal relapse, distant metastasis, recurrence-free survival, and overall survival were calculated by Kaplan-Meier method. Univariate analysis was performed by log rank test or Cox proportional hazards. Pretreatment CT images were analyzed for patients with VR. RESULTS Median follow-up was 42 months for 243 patients. The 3-year rates of VR, pelvic nodal relapse, distant metastasis, recurrence-free survival, and overall survival were 1.9%, 1.5%, 4.3%, 94.1%, and 98.9%, respectively. The 3-year VR rates by Gynecologic Oncology (GOG)-99 risk groups were 0%, 1.4%, and 3.2% for low risk, low-intermediate risk, and high-intermediate risk (HIR) disease (P = .5). By Post-operative Radiation Therapy in Endometrial Carcinoma (PORTEC) risk stratification, 3-year VR rate was 1.3% for HIR disease. On review of pretreatment CT images of the 6 patients with VR, 3 patients had relapse at the introitus outside of the treated vaginal length, and 3 had in-field recurrence at the vaginal apex. Higher body mass index (BMI) was associated with VR, with a 14% increase in risk per BMI unit (kg/m2, P = .02). There were no reported grade 2 GI or any grade 3 toxicities. CONCLUSIONS Adjuvant HDR VB with a low-dose regimen results in excellent clinical outcomes for patients with early stage endometrioid endometrial cancer. Patients with higher BMI may be at increased risk of VR, and additional study is needed to optimize brachytherapy treatment parameters.
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Affiliation(s)
- Gabriela M Alban
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniela L Buscariollo
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Teresa Cheng
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Pretz
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Betty Krechmer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Ivan Buzurovic
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Lisa Singer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Martin King
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Larissa Lee
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
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Zhang Y, Rovirosa A, Ascaso C, Herreros A, Torne A, Li Y, Biete A, Sánchez J. Economic impact of decreasing the fraction number in vaginal cuff brachytherapy: A direct cost analysis. Brachytherapy 2019; 19:60-65. [PMID: 31587986 DOI: 10.1016/j.brachy.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/29/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to analyze the direct economic impact of two vaginal cuff brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) with similar vaginal control and toxicity results. MATERIALS AND METHODS From 2006 to 2015, 397 PEC patients (p) were treated with VBT: mean 40p/year, 67.5% received external beam radiotherapy (EBRT)+VBT and 32.5% exclusive VBT. Schedule 1: 3 fractions (Fr) after EBRT and 6Fr (4-6 Gy/Fr) in exclusive VBT. Schedule 2: 7Gy × 1Fr + EBRT and 6Gy × 3Fr in exclusive VBT. Differential cost analysis of the two schedules was retrospectively performed. The direct costs in each schedule were (1) Personnel: radiotherapy technicians, nurses, radiation oncologists, medical physicists, administrative personnel, orderlies; time dedicated by each professional during CT planning acquisitions and delineation of vagina/organs at risk, dosimetric study and evaluation, autoradiography, procedure reporting time during/after treatment, removal of bladder/rectal tubes and applicators, material cleaning and transportation for sterilization; (2) Health care material (gels, gauzes, gloves, etc); (3) Equipment (time equipment used). The differential between the two schedules was estimated. Indirect costs and evaluation of quality of life-adjusted costs were not considered. RESULTS The overall reduction in the number of Fr per year in Schedule 2 was 93. Cost savings included treatment time per year: 4,185 min (70 h); personnel: 221€ ($246)/p in EBRT + VBT and 331€ ($368)/p in exclusive VBT; and health care material and equipment: 40€ ($44.5)/p in EBRT + VBT and 90€ ($100.2)/p in exclusive VBT. The overall savings per patient was 261€ ($295) in combined treatment and 421€ ($475.7) in exclusive VBT. The total savings per year with Schedule 2 in 40p was 12,503€ ($13,915.8). CONCLUSIONS A 41% reduction in the fractions number in VBT for PEC allowed economic savings of 261€ ($290.5)/p in combined treatment and 421€ ($475.7)/p in exclusive VBT. Other benefits include patient comfort and fewer treatment visits.
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Affiliation(s)
- Yaowen Zhang
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Angeles Rovirosa
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain; Gynaecological Cancer Unit, Gynaecology and Obtetrics Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain.
| | - Carlos Ascaso
- Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Antonio Herreros
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Aureli Torne
- Gynaecological Cancer Unit, Gynaecology and Obtetrics Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Yan Li
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Albert Biete
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Joan Sánchez
- Economics Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
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Guy CL, Fields EC, Quinn BA, Fisher CM, Ladbury CJ, Romano KD, Todor D. The vaginal cylinder: Misunderstood, misused, or trivial? An in-depth dosimetric and multiinstitutional outcome investigation. Brachytherapy 2019; 18:763-770. [PMID: 31558353 DOI: 10.1016/j.brachy.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/06/2019] [Accepted: 08/13/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE The purpose of the study was to investigate the impact on dose distribution and radiobiological metrics of common high-dose-rate vaginal brachytherapy treatment parameters and to analyze multiinstitutional data for clinically significant impact on outcomes in early-stage endometrial cancer. METHODS AND MATERIALS Treatment plans were created for all combinations of prescription parameters and used to quantify the dosimetric impact of each parameter and to estimate the dose delivered using common voxel-integrated radiobiological metrics. A rating system, based on risk grouping from GOG and PORTEC trials, was used to consolidate staging information into a cancer "aggressiveness" measure. Correlations between the rating, toxicity, disease recurrence, and plan parameters were investigated. RESULTS When prescribing to 5 mm depth, the variation caused by the diameter was very large across all dose metrics, ranging from 51% to 175% increase with the most divergence in BEDmax. For surface prescription, changing the cylinder diameter from 4 cm to 2 cm caused the dose metrics of BEDmin, Dmin, and gBEUD (a = -3) to increase by 117%, 67%, and 52%, respectively. Prescription to 5-mm depth caused changes across all dose metrics of 260% compared with surface prescription for a 2-cm cylinder. Deeper prescription point (p = 0.005) and longer treatment length (p = 0.01) were correlated with increased stenosis rates. No correlation between recurrence and any plan parameter was found. CONCLUSIONS Dramatic differences in dose distributions arise by small variations of plan parameters, with large impact on rates of vaginal stenosis, but no clear relation with local recurrence. To help radiation oncologists interpret the magnitude of these effects for their patients, we created a tool that allows comparison between dose and fractionation parameters.
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Affiliation(s)
- Christopher L Guy
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Bridget A Quinn
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | - Colton J Ladbury
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Dorin Todor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Damast S, Jeffery DD, Son CH, Hasan Y, Carter J, Lindau ST, Jhingran A. Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology. Pract Radiat Oncol 2019. [PMID: 31302301 DOI: 10.1016/j.prro.2019.07.001.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
PURPOSE Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology. METHODS AND MATERIALS A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions. RESULTS VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown. CONCLUSIONS This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.
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Affiliation(s)
- Shari Damast
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut.
| | - Diana D Jeffery
- Department of Defense, Defense Health Agency, Falls Church, Virginia
| | - Christina H Son
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Jeanne Carter
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; Department of Medicine-Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois; Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Damast S, Jeffery DD, Son CH, Hasan Y, Carter J, Lindau ST, Jhingran A. Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology. Pract Radiat Oncol 2019; 9:479-491. [PMID: 31302301 DOI: 10.1016/j.prro.2019.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/03/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology. METHODS AND MATERIALS A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions. RESULTS VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown. CONCLUSIONS This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.
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Affiliation(s)
- Shari Damast
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut.
| | - Diana D Jeffery
- Department of Defense, Defense Health Agency, Falls Church, Virginia
| | - Christina H Son
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Jeanne Carter
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; Department of Medicine-Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois; Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Albuquerque K, Hrycushko BA, Harkenrider MM, Mayadev J, Klopp A, Beriwal S, Petereit DG, Scanderbeg DJ, Yashar C. Compendium of fractionation choices for gynecologic HDR brachytherapy—An American Brachytherapy Society Task Group Report. Brachytherapy 2019; 18:429-436. [DOI: 10.1016/j.brachy.2019.02.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/07/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
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Ager BJ, Francis SR, Do OA, Huang YJ, Soisson AP, Dodson MK, Werner TL, Sause WT, Grant JD, Gaffney DK. Do vaginal recurrence rates differ among adjuvant vaginal brachytherapy regimens in early-stage endometrial cancer? Brachytherapy 2019; 18:453-461. [PMID: 31005603 DOI: 10.1016/j.brachy.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE We sought to retrospectively examine clinical outcomes for three adjuvant vaginal high-dose-rate (HDR) brachytherapy regimens after hysterectomy for early-stage endometrial cancer. METHODS Included were women of all ages from two independent hospital systems diagnosed with Stage I-II endometrial cancer of any grade between 2000 and 2016 who underwent hysterectomy followed by adjuvant vaginal cylinder HDR brachytherapy with either 7.0 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, 6.5 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, or 6.0 Gy × 5 fractions prescribed to the vaginal surface. Outcomes included vaginal recurrence (VR), pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival. RESULTS Of the 348 women, 45 (13%) received 7.0 Gy × 3 fractions, 259 (74%) received 6.5 Gy × 3 fractions, and 44 (13%) received 6.0 Gy × 5 fractions. Women receiving 5-fraction brachytherapy were more likely to be younger with a higher performance status. At a median follow-up of 4.5 years, VR rates were 2.2%, 0.8%, and 4.5%, respectively. Multivariate analysis revealed no significant differences in the risks for VR among brachytherapy regimens. Risks for VR, pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival did not differ between propensity score-matched five- and 3-fraction brachytherapy cohorts. CONCLUSIONS VR rates after hysterectomy and adjuvant vaginal brachytherapy for early-stage endometrial cancer were low and not significantly different by HDR dose fractionation.
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Affiliation(s)
- Bryan J Ager
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Samual R Francis
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Olivia A Do
- Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Andrew P Soisson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mark K Dodson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Theresa L Werner
- Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - William T Sause
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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Hentz C, McAlarnen L, Harkenrider M, Small W. Radiation Therapy in Endometrial Cancer. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_56-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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26
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Lee JH, Kim HN, Lim HS, Cho SO. Three‐dimensional‐printed vaginal applicators for electronic brachytherapy of endometrial cancers. Med Phys 2018; 46:448-455. [DOI: 10.1002/mp.13335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Ju Hyuk Lee
- Department of Nuclear and Quantum Engineering Korea Advanced Institute of Science and Technology Daejeon 305‐701 Republic of Korea
| | - Hyun Nam Kim
- Department of Nuclear and Quantum Engineering Korea Advanced Institute of Science and Technology Daejeon 305‐701 Republic of Korea
| | - Hyung San Lim
- Department of Nuclear and Quantum Engineering Korea Advanced Institute of Science and Technology Daejeon 305‐701 Republic of Korea
| | - Sung Oh Cho
- Department of Nuclear and Quantum Engineering Korea Advanced Institute of Science and Technology Daejeon 305‐701 Republic of Korea
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Vaginal toxicity after high-dose-rate endovaginal brachytherapy: 20 years of results. J Contemp Brachytherapy 2018; 10:559-566. [PMID: 30662479 PMCID: PMC6335557 DOI: 10.5114/jcb.2018.79713] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate vaginal toxicity (primary endpoint) and local control (secondary endpoint) in patients with endometrial cancer who underwent primary surgery and adjuvant high-dose-rate (HDR) endovaginal brachytherapy (BT). Material and methods In September 2017, the authors conducted a comprehensive literature search of the following electronic databases: PubMed, Web of Science, Scopus, and Cochrane library. In this systematic review, the authors included randomized trials, non-randomized trials, prospective studies, retrospective studies, and cases. The time period of the research included articles published from September 1997 to September 2017. Results Acute endovaginal toxicity occurred in less than 20.6% and all acute toxicities were G1-G2. The most common early side effects due to HDR-BT treatment were vaginal inflammation, vaginal irritation, dryness, discharge, soreness, swelling, and fungal infection. G1-G2 late toxicity occurred in less than 27.7%. Finally, G3-G4 late vaginal occurred in less than 2%. The most common late side effects consisted of vaginal discharge, dryness, itching, bleeding, fibrosis, telangiectasias, stenosis, short or narrow vagina, and dyspareunia. Conclusions The data suggest that HDR endovaginal brachytherapy, with or without chemotherapy, is very well tolerated with low rates of acute and late vaginal toxicities. Further prospective studies with higher numbers of patients and longer follow-up are necessary to evaluate acute and late toxicities after HDR endovaginal brachytherapy.
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28
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Stahl JM, Qian JM, Tien CJ, Carlson DJ, Chen Z, Ratner ES, Park HS, Damast S. Extended duration of dilator use beyond 1 year may reduce vaginal stenosis after intravaginal high-dose-rate brachytherapy. Support Care Cancer 2018; 27:1425-1433. [PMID: 30187220 DOI: 10.1007/s00520-018-4441-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vaginal dilators (VD) are recommended following vaginal or pelvic radiotherapy for patients with endometrial carcinoma (EC) to prevent vaginal stenosis (VS). The time course of VS is not fully understood and the optimal duration of VD use is unknown. METHODS We reviewed 243 stage IA-II EC patients who received adjuvant brachytherapy (BT) at an academic tertiary referral center. Patients were instructed to use their VD three times per week for at least 1-year duration. The primary outcome was development of grade ≥ 1 VS using CTCAEv4 criteria during the follow-up period. The log-rank test and multivariable Cox proportional hazards modeling were used to evaluate the effect of VD use (noncompliance vs. standard compliance [up to 1 year] vs. extended compliance [over 1 year]) on VS. RESULTS The median follow-up was 15.2 months over the 5-year study period. At 15 months, the incidence of VS was 38.8% for noncompliant patients, 33.5% for those with standard compliance, and 21.4% for those with extended compliance (median time to grade ≥ 1 VS was 17.5 months, 26.7 months, and not yet reached for these groups, respectively). On multivariable Cox regression analysis, extended compliance remained a significant predictor of reduced VS risk when compared to both noncompliance (HR 0.38, 95% CI 0.18-0.80, p = 0.012) and standard compliance (HR 0.43, 95% CI 0.20-0.89, p = 0.023). CONCLUSIONS The risk of VS persists beyond 1 year after BT. Extended VD compliance beyond 1 year may mitigate this risk.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.
| | - Jack M Qian
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J Tien
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Zhe Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Elena S Ratner
- Department of Gynecology and Reproductive Sciences, Section of Gynecologic Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
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Kim Y, Cabel K, Sun W. Does the apex optimization line matter for single-channel vaginal cylinder brachytherapy planning? J Appl Clin Med Phys 2018; 19:307-312. [PMID: 29766643 PMCID: PMC6036350 DOI: 10.1002/acm2.12351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 04/02/2018] [Accepted: 04/05/2018] [Indexed: 01/01/2023] Open
Abstract
The objective of this study is to test the impact of the use of the apex optimization line for new vaginal cylinder (VC) applicators. New single channel VC applicators (Varian) that have different top thicknesses but the same diameters as the old VC applicators (2.0 cm diameter, 2.3, 2.6, 3.0, and 3.5 cm) were compared using phantom studies. Old VC applicator plans without the apex optimization line were also compared to the plans with an apex optimization line. The apex doses were monitored at 5 mm depth doses (eight points) where a prescription dose (Rx) of 6 Gy was prescribed. VC surface doses (eight points) were also analyzed. The new VC applicator plans without apex optimization line presented significantly lower 5‐mm depth doses over the Rx (on average −31 ± 7%, P < 0.00001) due to thicker VC tops (3.4 ± 1.1 mm thicker with the range of 1.2–4.4 mm) than the old VC applicators. Old VC applicator plans also showed a statistically significant reduction (P < 0.00001) due to the Ir‐192 source anisotropic effect at the apex region, but the percent reduction over the Rx was only −7 ± 9%. However, by adding the apex optimization line to the new VC applicator plans, the plans improved 5‐mm depth doses (−7 ± 9% over Rx) that were not statistically different from old VC applicator plans (P = 0.923), along with apex VC surface doses (−22 ± 10% over old VC vs −46 ± 7% without using apex optimization line). The use of the apex optimization line is important in order to avoid significant additional cold doses (−24 ± 2%) at the prescription depth (5 mm) of the apex, specifically for the new VC applicators that have thicker tops. A template‐based vaginal cylinder planning reduced the intra‐ and inter‐planner variations of manual generation of apex optimization line, along with treatment time.
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Affiliation(s)
- Yusung Kim
- Department of Radiation Oncology; Carver College of Medicine; Iowa, City IA USA
| | - Katherine Cabel
- Department of Biomedical Engineering; College of Engineering; The University of Iowa; Iowa, City IA USA
| | - Wenqing Sun
- Department of Radiation Oncology; Carver College of Medicine; Iowa, City IA USA
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Late G2 vagina toxicity in post-operative endometrial carcinoma is associated with a 68 Gy dose equivalent to 2 Gy per fraction (α/β=3Gy) at 2 cm 3 of vagina. J Contemp Brachytherapy 2018; 10:40-46. [PMID: 29619055 PMCID: PMC5881596 DOI: 10.5114/jcb.2018.74140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/20/2018] [Indexed: 01/25/2023] Open
Abstract
Purpose To evaluate if the dose equivalent to 2 Gy per fraction (EQD2)(α/β=3Gy) at 0.1 cm3, 1 cm3, and 2 cm3 of vagina in vaginal-cuff-brachytherapy (VBT) (high-dose-rate [HDR] 192Ir-source) ± external-beam-irradiation (EBRT) is associated with toxicity in post-operative endometrial carcinoma (P-EC). Material and methods From June 2014 till November 2015, 67 consecutive P-EC patients underwent VBT ± EBRT; 44 patients received EBRT (median, 45 Gy; range, 44-50.4) + VBT (7 Gy), and 23 exclusive-VBT (6 Gy x 3 fractions). The upper 2.5 cm of vagina was delineated on computed tomography (CT). The active-length source was 2.5 cm, and the brachytherapy dose was prescribed at 5 mm from the applicator. D90, V100, and EQD2(α/β=3Gy) at 0.1 cm3, 1 cm3, and 2 cm3 of the most exposed part of the vagina were calculated. Vaginal toxicity assessment was completed with a LENT-SOMA-objective-criteria. Statistics were done with the use of χ2 and Student’s-t test. Results The mean follow-up was 23.2 months (7.6-46.8). Median D90 was 7.8 Gy(α/β=3Gy). Late toxicity: 8 G1 and 9 G2. Median EQD2(α/β=3Gy) in vagina was 88.6 Gy (62.8-177.6) for 0.1 cm3, 72.4 Gy (57.1-130.4) for 1 cm3, and 69 Gy (53-113.4) for 2 cm3. Exclusive VBT vs. EBRT+VBT showed no differences in vaginal toxicity. There was no relationship between EQD2(α/β=3Gy) at 0.1 cm3 and 1 cm3 of vagina with G1-G2 toxicity (p = 0.62 and p = 0.58, respectively). G2 toxicity was related to EQD2(α/β=3Gy) at 2 cm3 (p = 0.03). EQD2(α/β=3Gy) > 68 Gy caused G2 late toxicity in 20.5% patients. All patients presenting G2 toxicity received > 68 Gy EQD2(α/β=3Gy). Conclusions More than 68 Gy EQD2(α/β=3Gy) at 2 cm3 was related to G2 toxicity in P-EC-VBT. Further studies including larger number of patients are needed to confirm these results. Patients receiving these doses should be informed of the risk of toxicity, with individualized treatment planning and follow-up to reduce G2 toxicity.
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Qian JM, Stahl JM, Young MR, Ratner E, Damast S. Impact of vaginal cylinder diameter on outcomes following brachytherapy for early stage endometrial cancer. J Gynecol Oncol 2018; 28:e84. [PMID: 29027402 PMCID: PMC5641534 DOI: 10.3802/jgo.2017.28.e84] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/16/2017] [Accepted: 08/10/2017] [Indexed: 01/23/2023] Open
Abstract
Objective To examine the outcomes (tolerability, toxicity, and recurrence) of vaginal brachytherapy (VBT) among endometrial cancer (EC) patients treated with small cylinder size. Methods Patients with EC who received adjuvant VBT between September 2011 and December 2015 were reviewed. Patients were fitted with the largest vaginal cylinder they could comfortably accommodate, from 2.0–3.0 cm diameter. Small cylinders were defined as size 2.3 cm or less. Patient, tumor, or treatment characteristics were correlated with need for small cylinders. Treatment tolerability, measures of gastrointestinal (GI), genitourinary (GU), and vaginal toxicity, and rates of recurrence were analyzed. Results Three hundred four patients were included. Small cylinders were used in 51 patients (17%). Normal body mass index (BMI; p<0.001), nulligravidity (p<0.001), and shorter vaginal length (p<0.001) were associated with small cylinder size. There was no acute or late grade 3 toxicity. Rates of acute (grade 1–2) GI, GU, or vaginal symptoms were low (10%, 11%, and 19%, respectively). Small cylinder size was associated with increased likelihood of reporting acute GI (p<0.05) but not GU or vaginal symptoms. Small cylinder size was associated with higher risk of grade 1–2 vaginal stenosis (odds ratio [OR]=4.7; 95% confidence interval [CI]=1.5–14.7; p=0.007). There was no association between cylinder size and recurrence rate (p=0.55). Conclusion VBT is generally very well tolerated, however, patients fitted with smaller cylinders (commonly nulligravid and low BMI) may have increased side effects. Further study to improve the dosimetry of VBT for patients requiring small cylinders may be worthwhile.
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Affiliation(s)
- Jack M Qian
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - John M Stahl
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Melissa R Young
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Elena Ratner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA.
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Grelewicz Z, Zerrusen B, Sathiaseelan V, Zhang H. A feasibility study of using advanced external beam techniques to create a vaginal cuff brachytherapy-like endometrial boost plan. Med Dosim 2018; 43:30-38. [DOI: 10.1016/j.meddos.2017.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/05/2017] [Accepted: 07/26/2017] [Indexed: 10/18/2022]
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Chargari C, Maroun P, Lazarescu I, Haie-Meder C. [Clinical trials and perspectives of radiotherapy for uterine endometrial cancers]. Bull Cancer 2017; 104:1039-1045. [PMID: 29100604 DOI: 10.1016/j.bulcan.2017.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 10/18/2022]
Abstract
The adjuvant management of uterine endometrial cancer has been studied in many randomized trials, leading to define postoperative therapeutic indications, depending on the risk factors for relapse, and on the expected benefit in terms of locoregional control and survival. The potential toxicity of treatments should be also considered. We review the available literature that yielded to guidelines that were recently published, on behalf of European societies, and we highlight the perspectives on ongoing studies, aimed at better defining the place and type of adjuvant treatment.
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Affiliation(s)
- Cyrus Chargari
- Gustave-Roussy Cancer Campus, service de curiethérapie, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Gustave-Roussy Cancer Campus, radiothérapie moléculaire, UMR 1030, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Institut de recherche biomédicale des armées, D19, effets biologiques des rayonnements, 91220 Brétigny-sur-Orge, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France.
| | - Pierre Maroun
- Gustave-Roussy Cancer Campus, service de curiethérapie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Ioana Lazarescu
- Gustave-Roussy Cancer Campus, service de curiethérapie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Christine Haie-Meder
- Gustave-Roussy Cancer Campus, service de curiethérapie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
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Tailoring Adjuvant Radiotherapy in Endometrial Cancer. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2017. [DOI: 10.1007/s40944-017-0136-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sabater S, Andres I, Lopez-Honrubia V, Berenguer R, Sevillano M, Jimenez-Jimenez E, Rovirosa A, Arenas M. Vaginal cuff brachytherapy in endometrial cancer - a technically easy treatment? Cancer Manag Res 2017; 9:351-362. [PMID: 28848362 PMCID: PMC5557121 DOI: 10.2147/cmar.s119125] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.
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Affiliation(s)
- Sebastià Sabater
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Ignacio Andres
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | - Roberto Berenguer
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Marimar Sevillano
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | | | - Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan, Reus, Spain
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Kachnic LA, Bruner DW, Qureshi MM, Russo GA. Perceptions and practices regarding women's vaginal health following radiation therapy: A survey of radiation oncologists practicing in the United States. Pract Radiat Oncol 2017; 7:356-363. [PMID: 28377136 DOI: 10.1016/j.prro.2017.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 01/31/2017] [Accepted: 02/10/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Vaginal stenosis (VS) is a recognized complication of pelvic and vaginal radiation therapy (RT). METHODS AND MATERIALS A 26-item survey assessing the signs/symptoms, risk factors, diagnosis, prevention, treatment, and impact of VS on women's sexual health was distributed to radiation oncologists. Descriptive statistics were calculated. Chi-square tests examined differences in categorical responses. RESULTS A total of 233 (10.5%) participants completed the entire survey. Twelve percent, 21%, and 68% report treating gynecologic (GYN) tumors only, non-GYN pelvic tumors only, or both, respectively. Regarding risk factors, 78% believed that VS can be caused by pelvic RT alone, 91% by vaginal brachytherapy alone, and 98% by combined pelvic RT and vaginal brachytherapy. Approximately one-half of respondents felt that being postmenopausal and having a hysterectomy before radiation therapy were risk factors for VS, whereas the other half felt that these were not risk factors. All respondents agreed that VS is a clinical diagnosis. Respondents indicated that VS symptoms include dyspareunia, vaginal pain, dryness, and/or bleeding (100%, 90%, 85%, and 72%, respectively); 65% indicated all 4. The most commonly recommended treatment for VS is vaginal dilator use. Radiation oncologists who treat GYN-only versus non-GYN cancers were more likely to perform a vaginal examination, to distribute written instructions regarding vaginal dilator use (P = .002), to have vaginal bleeding reported after RT (P = .001), and to refer patients to a sexual counselor (P = .007). Most providers (73%) expressed willingness to participate in prospective research on the diagnosis and treatment of VS. CONCLUSIONS This is the first large-scale survey of radiation oncologists' perceptions and practices regarding VS. There is agreement among providers regarding the signs/symptoms of VS and strategies for its prevention/treatment using vaginal dilators. Further prospective and observational research is needed. This survey shows a willingness on the part of providers to take part in prospective research regarding the diagnosis, impact, and treatment of VS on women's sexual health.
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Affiliation(s)
- Lisa A Kachnic
- Vanderbilt Ingram Cancer Center, Vanderbilt University, Nashville, Tennessee
| | | | | | - Gregory A Russo
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Acute and late vaginal toxicity after adjuvant high-dose-rate vaginal brachytherapy in patients with intermediate risk endometrial cancer: is local therapy with hyaluronic acid of clinical benefit? J Contemp Brachytherapy 2016; 8:512-517. [PMID: 28115957 PMCID: PMC5241378 DOI: 10.5114/jcb.2016.64511] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/17/2016] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The aim of the present study was to evaluate the effectiveness of hyaluronic acid (HA) in the prevention of acute and late vaginal toxicities after high-dose-rate (HDR) vaginal brachytherapy (BT). MATERIAL AND METHODS Between January 2011 and January 2015, we retrospectively analyzed 126 patients with endometrial cancer who underwent extrafascial hysterectomy with or without lymphadenectomy and adjuvant HDR-vaginal BT +/- adjuvant chemotherapy. The total dose prescription was 21 Gy in 3 fractions (one fraction for week). Vaginal ovules containing 5 mg of HA were given for whole duration of vaginal BT and for the two following weeks. Acute and late toxicities were evaluated according to CTCAE vs 4.02. RESULTS According to the revised FIGO 2009 classification, most tumors were in stage IA (30.9%) and in stage IB (57.9%). Thirty-three patients (26.2%) received adjuvant chemotherapy before vaginal BT. Five-year disease-free survival (DFS) and five-year overall survival (OS) were 88% and 93%, respectively. The most common grade 1-2 acute toxicities were vaginal inflammation (18 patients, 14.3%) and dyspareunia (7 patients, 5.5%). Two patients (1.6%) had more than one toxicity. Late toxicity occurred in 20 patients (15.9%). Grade 1-2 late toxicities were fibrosis (14 patients, 11.1%) and telangiectasias (7 patients, 5.5%). Six patients (4.8%) had more than one late toxicity. No grade 3 or higher acute or late toxicities were observed. CONCLUSIONS These results appear to suggest that the local therapy with HA is of clinical benefit for intermediate risk endometrial cancer patients who receive adjuvant HDR-vaginal BT after surgery. A randomized trial comparing HA treatment vs. no local treatment in this clinical setting is warranted to further evaluate the efficacy of HA in preventing vaginal BT-related vaginal toxicity.
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The dosimetric impact of air in vaginal vault brachytherapy. Brachytherapy 2016; 15:832-838. [DOI: 10.1016/j.brachy.2016.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/10/2016] [Accepted: 08/08/2016] [Indexed: 11/22/2022]
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Kim J, Lee KJ, Park KR, Ha B, Kim YJ, Jung W, Lee R, Kim SC, Moon HS, Ju W, Kim YH, Lee J. Treatment outcomes after adjuvant radiotherapy following surgery for patients with stage I endometrial cancer. Radiat Oncol J 2016; 34:265-272. [PMID: 27703126 PMCID: PMC5207367 DOI: 10.3857/roj.2016.01648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/08/2016] [Accepted: 06/30/2016] [Indexed: 01/17/2023] Open
Abstract
PURPOSE The purpose of this study is to evaluate the treatment outcomes of adjuvant radiotherapy using vaginal brachytherapy (VB) with a lower dose per fraction and/or external beam radiotherapy (EBRT) following surgery for patients with stage I endometrial carcinoma. MATERIALS AND METHODS The subjects were 43 patients with the International Federation of Gynecology and Obstetrics (FIGO) stage I endometrial cancer who underwent adjuvant radiotherapy following surgery between March 2000 and April 2014. Of these, 25 received postoperative VB alone, while 18 received postoperative EBRT to the whole pelvis; 3 of these were treated with EBRT plus VB. The median EBRT dose was 50.0 Gy (45.0-50.4 Gy) and the VB dose was 24 Gy in 6 fractions. Tumor dose was prescribed at a depth of 5 mm from the cylinder surface and delivered twice per week. RESULTS The median follow-up period for all patients was 57 months (range, 9 to 188 months). Five-year disease-free survival (DFS) and overall survival (OS) for all patients were 92.5% and 95.3%, respectively. Adjuvant radiotherapy was performed according to risk factors and stage IB, grade 3 and lymphovascular invasion were observed more frequently in the EBRT group. Five-year DFS for EBRT and VB alone were 88.1% and 96.0%, respectively (p = 0.42), and 5-year OS for EBRT and VB alone were 94.4% and 96%, respectively (p = 0.38). There was no locoregional recurrence in any patient. Two patients who received EBRT and 1 patient who received VB alone developed distant metastatic disease. Two patients who received EBRT had severe complications, one each of grade 3 gastrointestinal complication and pelvic bone insufficiency fracture. CONCLUSION Adjuvant radiotherapy achieved high DFS and OS with acceptable toxicity in stage I endometrial cancer. VB (with a lower dose per fraction) may be a viable option for selected patients with early-stage endometrial cancer following surgery.
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Affiliation(s)
- Jiyoung Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Ja Lee
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Ran Park
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Boram Ha
- Proton Therapy Center, National Cancer Center, Goyang, Korea
| | - Yi-Jun Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Wonguen Jung
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Rena Lee
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seung Cheol Kim
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye Sung Moon
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Woong Ju
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yun Hwan Kim
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jihae Lee
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
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Zhang H, Gopalakrishnan M, Lee P, Kang Z, Sathiaseelan V. Dosimetric impact of cylinder size in high-dose rate vaginal cuff brachytherapy (VCBT) for primary endometrial cancer. J Appl Clin Med Phys 2016; 17:262-272. [PMID: 27685113 PMCID: PMC5874121 DOI: 10.1120/jacmp.v17i5.6182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 04/15/2016] [Accepted: 05/16/2016] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to evaluate the dosimetric impact of cylinder size in high‐dose‐rate (HDR) vaginal cuff brachytherapy (VCBT). Sample plans of HDR VCBT in a list of cylinders ranging from 2.5 to 4 cm in diameter at 0.5 cm increment were created and analyzed. The doses were prescribed either at the 0.5 cm depth with 5.5 Gy for 4 fractions or at the cylinder surface with 8.8 Gy for 4 fractions, in various treatment lengths. A 0.5 cm shell volume called PTV_Eval was contoured for each plan and served as the target volume for dosimetric evaluation. The cumulative and differential dose volume histograms (c‐DVH and d‐DVH), mean doses (D‐mean) and the doses covering 90% (D90), 10% (D10), and 5% (D5) of PTV_Eval were calculated. In the 0.5 cm depth regimen, the DVH curves were found to have shifted toward the lower dose zone when a larger cylinder was used, but in the surface regimen the DVH curves shifted toward the higher dose zone as the cylinder size increased. The D‐means of the both regimens were between 6.9 and 7.8 Gy and dependent on the cylinder size but independent of the treatment length. A 0.5 cm variation of diameter could result in a 4% change of D‐mean. Average D90s were 5.7 (ranging from 5.6 to 5.8 Gy) and 6.1 Gy (from 5.7 to 6.4 Gy), respectively, for the 0.5 cm and surface regimens. Average D10 and D5 were 9.2 and 11 Gy, respectively, for the 0.5 cm depth regimen, and 8.9 and 9.7 Gy, respectively, for the surface regimen. D‐mean, D90, D10, and D5 for other prescription doses could be calculated from the lookup tables of this study. Results indicated that the cylinder size has moderate dosimetric impact, and that both regimens are comparable in dosimetric quality. PACS number(s): 87.61.‐c, 87.53.Jw, 87.19.xj
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Affiliation(s)
- Hualin Zhang
- Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital.
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MRI-Based Evaluation of the Vaginal Cuff in Brachytherapy Planning: Are We Missing the Target? Int J Radiat Oncol Biol Phys 2016; 95:743-50. [PMID: 27020110 DOI: 10.1016/j.ijrobp.2016.01.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/08/2016] [Accepted: 01/20/2016] [Indexed: 02/08/2023]
Abstract
PURPOSE Although recurrences and toxicity occur after vaginal cuff (VC) brachytherapy, little is known about dosimetry due to the inability to clearly visualize the VC on computed tomography (CT). T2-weighted (T2W) magnetic resonance imaging (MRI) is superior to CT in this setting, and we hypothesized that it could provide previously unascertainable dosimetric information. METHODS AND MATERIALS In a cohort of 32 patients who underwent cylinder-based brachytherapy for endometrial cancer with available MR simulation images, the VC was retrospectively contoured on T2W images, and cases were replanned to treat the upper VC to a dose of 7 Gy/fraction prescribed to 5 mm. Relevant dose-volume parameters for the VC were calculated. RESULTS T2W MRI identified significant underdosing not observed on CT or T1-weighted imaging. Over two-thirds (69%) of patients had at least 1 cm(3) of VC that received less than 75% of the prescription dose and half (50%) of patients had a least 1 cm(3) of VC that received less than 50% of the prescription dose. The mean minimum point dose to the VC was 2.4 Gy, or 34% of the intended prescription dose (range: 0.53-6.4 Gy). CONCLUSIONS We identified previously unreported VC underdosing in over two-thirds of our patients, with most of these patients having volumes of undistended VC that received less than half of the prescription dose. The maximum dimension was along the craniocaudal axis in some patients or left-right/anterior-posterior axis in others, suggesting that suture material may be restricting access to the vaginal apex and that alternative applicators may be needed when the diameter of the apex is larger than the introitus. Additional follow-up will be needed to determine whether underdosing is associated with isolated VC failure or whether low failure rates across the cohort suggest that some patients are being exposed to excessive dose and unnecessary risk of toxicity.
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Zhang H, Donnelly ED, Strauss JB, Qi Y. Therapeutic analysis of high-dose-rate (192)Ir vaginal cuff brachytherapy for endometrial cancer using a cylindrical target volume model and varied cancer cell distributions. Med Phys 2016; 43:483. [PMID: 26745941 DOI: 10.1118/1.4939064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To evaluate high-dose-rate (HDR) vaginal cuff brachytherapy (VCBT) in the treatment of endometrial cancer in a cylindrical target volume with either a varied or a constant cancer cell distributions using the linear quadratic (LQ) model. METHODS A Monte Carlo (MC) technique was used to calculate the 3D dose distribution of HDR VCBT over a variety of cylinder diameters and treatment lengths. A treatment planning system (TPS) was used to make plans for the various cylinder diameters, treatment lengths, and prescriptions using the clinical protocol. The dwell times obtained from the TPS were fed into MC. The LQ model was used to evaluate the therapeutic outcome of two brachytherapy regimens prescribed either at 0.5 cm depth (5.5 Gy × 4 fractions) or at the vaginal mucosal surface (8.8 Gy × 4 fractions) for the treatment of endometrial cancer. An experimentally determined endometrial cancer cell distribution, which showed a varied and resembled a half-Gaussian distribution, was used in radiobiology modeling. The equivalent uniform dose (EUD) to cancer cells was calculated for each treatment scenario. The therapeutic ratio (TR) was defined by comparing VCBT with a uniform dose radiotherapy plan in term of normal cell survival at the same level of cancer cell killing. Calculations of clinical impact were run twice assuming two different types of cancer cell density distributions in the cylindrical target volume: (1) a half-Gaussian or (2) a uniform distribution. RESULTS EUDs were weakly dependent on cylinder size, treatment length, and the prescription depth, but strongly dependent on the cancer cell distribution. TRs were strongly dependent on the cylinder size, treatment length, types of the cancer cell distributions, and the sensitivity of normal tissue. With a half-Gaussian distribution of cancer cells which populated at the vaginal mucosa the most, the EUDs were between 6.9 Gy × 4 and 7.8 Gy × 4, the TRs were in the range from (5.0)(4) to (13.4)(4) for the radiosensitive normal tissue depending on the cylinder size, treatment lengths, prescription depth, and dose as well. However, for a uniform cancer cell distribution, the EUDs were between 6.3 Gy × 4 and 7.1 Gy × 4, and the TRs were found to be between (1.4)(4) and (1.7)(4). For the uniformly interspersed cancer and radio-resistant normal cells, the TRs were less than 1. The two VCBT prescription regimens were found to be equivalent in terms of EUDs and TRs. CONCLUSIONS HDR VCBT strongly favors cylindrical target volume with the cancer cell distribution following its dosimetric trend. Assuming a half-Gaussian distribution of cancer cells, the HDR VCBT provides a considerable radiobiological advantage over the external beam radiotherapy (EBRT) in terms of sparing more normal tissues while maintaining the same level of cancer cell killing. But for the uniform cancer cell distribution and radio-resistant normal tissue, the radiobiology outcome of the HDR VCBT does not show an advantage over the EBRT. This study strongly suggests that radiation therapy design should consider the cancer cell distribution inside the target volume in addition to the shape of target.
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Affiliation(s)
- Hualin Zhang
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611
| | - Eric D Donnelly
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611
| | - Jonathan B Strauss
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611
| | - Yujin Qi
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW 2522, Australia
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Kirchheiner K, Nout RA, Lindegaard JC, Haie-Meder C, Mahantshetty U, Segedin B, Jürgenliemk-Schulz IM, Hoskin PJ, Rai B, Dörr W, Kirisits C, Bentzen SM, Pötter R, Tanderup K. Dose-effect relationship and risk factors for vaginal stenosis after definitive radio(chemo)therapy with image-guided brachytherapy for locally advanced cervical cancer in the EMBRACE study. Radiother Oncol 2016; 118:160-6. [PMID: 26780997 DOI: 10.1016/j.radonc.2015.12.025] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/22/2015] [Accepted: 12/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE To identify risk factors for vaginal stenosis and to establish a dose-effect relationship for image-guided brachytherapy in locally advanced cervical cancer. MATERIALS/METHODS Patients from the ongoing EMBRACE study with prospectively assessed morbidity (CTCAEv3.0) at baseline and at least one follow-up were selected. Patient-, disease- and treatment characteristics were tested as risk factors for vaginal stenosis G ⩾ 2 in univariate and multivariable analyses (Cox proportional hazards model) and a dose-effect curve was deduced from the estimates. The ICRU rectum point was used to derive the recto-vaginal reference point dose. RESULTS In 630 patients included (median follow-up 24months), 2-year actuarial estimate for vaginal stenosis G ⩾ 2 was 21%. Recto-vaginal reference point dose (HR=1.025, p=0.029), external beam radiotherapy (EBRT) dose >45 Gy/25 fractions (HR=1.770, p=0.056) and tumor extension in the vagina (HR=2.259, p ⩽ 0.001) were risk factors for vaginal stenosis, adjusted for center reporting effects. Based on the model curve, the risk was 20% at 65 Gy, 27% at 75 Gy and 34% at 85 Gy (recto-vaginal reference point dose). CONCLUSION Keeping the EBRT dose at 45 Gy/25 fractions and decreasing the dose contribution of brachytherapy to the vagina decrease the risk of stenosis. A planning aim of ⩽65 Gy EQD2 (EBRT+brachytherapy dose) to the recto-vaginal reference point is therefore proposed.
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Affiliation(s)
- Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria.
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | | | | | | | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | | | | | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Wolfgang Dörr
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria; Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria; Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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Gynecologic Brachytherapy: Endometrial Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gill BS, Minkoff D, Beriwal S. Current Concepts in Radiation Therapy for Early-Stage Endometrial Cancer. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2015. [DOI: 10.1007/s40944-015-0023-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Vaginal brachytherapy for postoperative endometrial cancer: 2014 Survey of the American Brachytherapy Society. Brachytherapy 2015; 15:23-9. [PMID: 26620818 DOI: 10.1016/j.brachy.2015.09.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/25/2015] [Accepted: 09/30/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE Report current practice patterns for postoperative endometrial cancer emphasizing vaginal brachytherapy (VBT). METHODS AND MATERIALS A 38-item survey was e-mailed to 1,598 American Brachytherapy Society (ABS) members and 4,329 US radiation oncologists in 2014 totaling 5,710 recipients. Responses of practitioners who had delivered VBT in the previous 12 months were included in the analysis. Responses were tabulated to determine relative frequency distributions. χ(2) analysis was used to compare current results with those from the 2003 ABS survey. RESULTS A total of 331 respondents initiated the VBT survey, of whom 289 (87.3%) administered VBT in the prior 12 months. Lymph node dissection and number of nodes removed influenced treatment decisions for 90.5% and 69.8%, respectively. High-dose-rate was used by 96.2%. The most common vaginal length treated was 4 cm (31.0%). Three-dimensional planning was used by 83.2% with 73.4% of those for the first fraction only. Doses to normal tissues were reported by 79.8%. About half optimized to the location of dose specification and/or normal tissues. As monotherapy, the most common prescriptions were 7 Gy for three fractions to 0.5-cm depth and 6 Gy for five fractions to the surface. As a boost, the most common prescriptions were 5 Gy for three fractions to 0.5-cm depth and 6 Gy for three fractions to the vaginal surface. Optimization points were placed at the apex and lateral vagina by 73.1%. Secondary quality assurance checks were performed by 98.9%. CONCLUSIONS VBT is a common adjuvant therapy for endometrial cancer patients, most commonly with HDR. Fractionation and planning processes are variable but generally align with ABS recommendations.
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İnan AH, Ersoy GŞ, Yıldırım Y, Gürbüz T, Kebapçılar AG, Hanhan M. Is adjuvant radiotherapy necessary for FIGO stage 1a grade 2 endometrial endometrioid adenocarcinoma? J Turk Ger Gynecol Assoc 2015; 16:153-7. [PMID: 26401108 DOI: 10.5152/jtgga.2015.15163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 05/14/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The impact of adjuvant radiotherapy on the rates of survival and local recurrence was analyzed in patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage 1a grade 2 endometrial endometrioid adenocarcinoma. MATERIAL AND METHODS Medical records of 82 patients diagnosed and treated for FIGO stage 1a grade 2 endometrial endometrioid adenocarcinoma were reviewed retrospectively. A group of 59 patients who received postoperative radiotherapy was compared with a control group of 23 subjects treated without adjuvant radiotherapy; the duration of survival as well as the local recurrence and metastasis rates were evaluated in both groups. RESULTS The analysis of patient data has revealed the rate of local recurrence as 4.3% vs. 1.7% (p=0.485), the rate of distant metastasis as 4.3% vs. 6.9% (p=1.000), and the mean survival time as 83.6±38.7 vs. 81.5±37.5 months (p=0.828) in the adjuvant radiotherapy and control groups, respectively. CONCLUSION In the presented study, adjuvant radiotherapy failed to improve the overall survival of the patients in the low-risk group (stage 1a grade 2). With the addition of the significant risk of radiation toxicity, it is highly probable that these patients will not benefit from postoperative radiotherapy. Close observation should be performed following the primary surgery in this patient group. Nevertheless, it should also be considered that adjuvant radiotherapy is a very effective treatment modality for the recovery of patients with vaginal relapse.
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Affiliation(s)
| | - Gülçin Şahin Ersoy
- Department of Obstetrics and Gynecology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Yusuf Yıldırım
- Department of Obstetrics and Gynecology, Divison of Gynecologic Oncology, Erzincan University Faculty of Medicine, Erzincan, Turkey
| | - Tutku Gürbüz
- Clinic of Obstetrics and Gynecology, Ardahan State Hospital, Ardahan, Turkey
| | - Ayşe Gül Kebapçılar
- Department of Obstetrics and Gynecology, Selçuk University Faculty of Medicine, Konya, Turkey
| | - Merih Hanhan
- Clinic of Obstetrics and Gynecology, Divison of Gynecologic Oncology, İzmir Aegean Obstetrics and Gynecology Education and Research Hospital, İzmir, Turkey
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Son CH, Law E, Oh JH, Apte AP, Yang TJ, Riedel E, Wu AJ, Deasy JO, Goodman KA. Dosimetric Predictors of Radiation-Induced Vaginal Stenosis After Pelvic Radiation Therapy for Rectal and Anal Cancer. Int J Radiat Oncol Biol Phys 2015; 92:548-54. [PMID: 25936810 DOI: 10.1016/j.ijrobp.2015.02.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 02/07/2015] [Accepted: 02/17/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Although vaginal stenosis (VS) is a recognized toxicity in women who receive pelvic radiation therapy (RT), the relationship between RT dose and the volume and extent of toxicity has not been analyzed. We modeled this relationship to identify predictors of VS. METHODS AND MATERIALS We evaluated 54 women, aged 29 to 78 years, who underwent pelvic RT for rectal or anal cancer during 2008 to 2011 and were enrolled in a prospective study evaluating vaginal dilator use. Maximum dilator size was measured before RT (baseline) and 1 month and 12 months after RT. Dilator use was initiated at 1 month. The difference (D) in dilator size before and after RT was recorded. Those with D ≤-1 were classified as having VS (n=35); those with D ≥0 were classified as having no VS (n=19 at 1 month). Dose-volume parameters were extracted, and the generalized equivalent uniform dose (gEUD) was used to build a predictive model. RESULTS The mean vaginal doses were 50.0 Gy and 36.8 Gy for anal and rectal cancer patients, respectively. One month after RT, a gEUD model using a wide range of a values suggests that sparing of vaginal volume to a low dose may be important. When gEUD (a = -1) was <35 Gy and the mean vaginal dose was <43 Gy, severe VS was reduced (P=.02). A 1-year analysis suggests increasingly negative D values with increasing mean dose. However, patients with compliance <40% were more likely to have toxicity. CONCLUSIONS Vaginal stenosis is influenced by multiple RT dose-volume characteristics. Mean dose and gEUD constraints together may reduce the risk of severe VS. Patients receiving higher mean vaginal doses should have greater compliance with dilator therapy to minimize risk of toxicity. Further validation with independent datasets is needed.
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Affiliation(s)
- Christina H Son
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ethel Law
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Aditya P Apte
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Elyn Riedel
- Department of Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Karyn A Goodman
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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Predictors of vaginal stenosis after intravaginal high-dose-rate brachytherapy for endometrial carcinoma. Brachytherapy 2015; 14:464-70. [PMID: 25887343 DOI: 10.1016/j.brachy.2015.03.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 01/27/2015] [Accepted: 03/03/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Intravaginal high-dose-rate brachytherapy is an effective adjuvant treatment for localized endometrial carcinoma. However, relatively little is known about risk factors of post-treatment vaginal stenosis (VS). METHODS AND MATERIALS We included patients treated with brachytherapy for endometrial carcinoma from September 2011 to January 2014 with at least 3 months of followup. Patients who received external beam radiation therapy were excluded. VS was prospectively graded at each followup visit per Common Terminology Criteria for Adverse Events, version 4.03. χ(2) and t test analyses were used to assess the association of VS with various patient, tumor, treatment, and post-treatment factors. Multivariable logistic regression analysis was used to identify independent predictors of VS Grade ≥1 and ≥2. RESULTS All 101 patients were disease free at last followup. Mean followup was 12.9 months (range, 3-34). Highest VS grades were zero in 67%, one in 26%, two in 6%, and three in 1%. Borderline significant variables associated with Grade ≥1 VS included vagina length, proportion of vagina treated, and total dose. Dilator use was significantly associated with Grade ≥2. Multivariable analysis revealed that proportion of vagina treated >60% (odds ratio [OR], 3.48; p = 0.009) and total dose >14 Gy (OR, 4.27; p = 0.015) were independent predictors of Grade ≥1 VS, and lack of consistent dilator use was an independent predictor of Grade ≥2 VS (OR, 5.60; p = 0.047). CONCLUSIONS Patients treated with a higher total dose to a larger proportion of the vagina were more likely to develop Grade ≥1 VS. Consistent dilator use may also be protective against Grade ≥2 VS.
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A novel intracavitary applicator design for the treatment of deep vaginal fornices: preliminary dose metrics and geometric analysis. J Contemp Brachytherapy 2015; 7:48-54. [PMID: 25829937 PMCID: PMC4371065 DOI: 10.5114/jcb.2015.49017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/16/2014] [Accepted: 12/27/2014] [Indexed: 11/17/2022] Open
Abstract
Purpose To investigate the dose distributions associated with a novel balloon sleeve placed over a standard cylinder applicator. Material and methods A computed tomography (CT) scan of a sleeve balloon shaped to inflate into the vaginal fornices was used to digitize 1-, 3-, and 5-catheter configurations. Point doses for rectum, apex, and fornix were calculated and compared to the values associated with a standard cylinder plan not targeting the vaginal fornices. Inflation of the sleeve balloon in the vaginal fornices and dose coverage with constraints to the rectum, bladder, and sigmoid D2cc were evaluated. Results Rectum, apex, and fornix doses were respectively 76%, 119%, and 44% for a standard cylinder; 190%, 310%, and 93% for a 1-catheter configuration; 98%, 109%, and 109% for a 3-catheter configuration; and 91%, 107%, and 96% for the 5-catheter configuration. In a patient analysis, expansion of the sleeve balloon into the vaginal fornices was confirmed. The 5-catheter configurations were associated with best coverage of the fornices and acceptable doses to rectum, bladder, and sigmoid. Conclusions A 1-catheter configuration cannot be used clinically due to high rectal and apex dose. In theoretical analysis, the 3- and 5-catheter configurations showed > 96% coverage to the vaginal fornices with a clinically acceptable rectal dose. In a treatment simulation in a patient, a 5-catheter configuration showed 90% coverage of the fornices with acceptable doses to the organs at risk. The treatment of deep vaginal fornices results in an increased rectal dose compared to a standard cylinder plan.
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