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Wernicke AG, Parashar B, Samuel E, Sabbas A, Gupta D, Caputo T. Partial-Length Treatment With Brachytherapy in Patients With Endometrial Cancer With High-Risk Features Is as Effective as Full-Length Vaginal Brachytherapy but With Reduced Toxicity. Pract Radiat Oncol 2023; 13:e416-e422. [PMID: 37295725 DOI: 10.1016/j.prro.2023.05.009] [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: 12/12/2022] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Full-length vaginal (FLV) brachytherapy for patients with endometrial cancer and high-risk features should be considered as per the American Brachytherapy Society to reduce distal vaginal recurrence in patients with endometrial cancers with papillary serous/clear cell histologies, grade 3 status, or extensive lymphovascular invasion. We sought to investigate this patient population and report outcomes of treatment with high-dose-rate (HDR) brachytherapy in women treated with FLV brachytherapy versus partial-length vaginal (PLV) brachytherapy. METHODS AND MATERIALS With institutional review board approval, we identified patients with endometrial cancer meeting American Brachytherapy Society criteria of high-risk features treated with adjuvant HDR between 2004 and 2010. HDR doses were 21Gy in 3 fractions delivered to either the full-length or partial-length vagina. Acute and late toxicities were evaluated using the Radiation Therapy Oncology Group scale and Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer grading, respectfully. Vaginal recurrences were assessed by physical examination and pap smears. Statistical analyses were performed using SPSS version 23 software. RESULTS Of 240 patients treated with HDR brachytherapy, 121 were treated with FLV brachytherapy, and 119, with PLV brachytherapy. The median follow-up was 9.5 years (range, 8-11 years) for FLV patients and 8.5 years (range, 7-10 years) for PLV patients; 0% of patients had vaginal recurrences, and 1.4% and 0.9% had proximal vaginal recurrences, respectively (P = .54). All patients treated with FLV brachytherapy developed grade 3 mucositis of the lower vagina/introitus (P < .0001) and had increased analgesics use compared with those treated with PLV brachytherapy (P < .0001). In total, 23% of patients treated with FLV brachytherapy developed grade 3 stenosis of the lower vagina/introitus, in contrast to 0% of patients treated with PLV brachytherapy (P < .0001). CONCLUSIONS PLV brachytherapy is as effective as FLV brachytherapy in reducing local recurrence and causes a significantly lower incidence of acute and late toxicities. The results of this study caution radiation oncologists regarding the careful use of FLV brachytherapy in patients with endometrial cancer and high-risk features.
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Affiliation(s)
- A Gabriella Wernicke
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York; Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York.
| | - Bhupesh Parashar
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Eileen Samuel
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Albert Sabbas
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York
| | - Divya Gupta
- Senior Group Medical Directory, GlaxoSmithKline, Waltham, Massachusetts
| | - Thomas Caputo
- Department of Obstetrics and Gynecology, Division of Gynecological Oncology, Weill Medical College of Cornell University, New York, New York
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Small W, Kim YS, Joyce C, Surucu M, Leshyk M, Harkenrider MM, Potkul RK, Liotta M, Winder A, Altoos B. Uterine perforation during brachytherapy for cervical cancer: Complications, outcomes, and best practices for forward treatment planning and management. Brachytherapy 2021; 20:557-564. [PMID: 33741275 DOI: 10.1016/j.brachy.2021.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of the study was to determine the incidence of uterine perforations, review the associated complications, and propose guidelines for management of perforations after brachytherapy. METHODS AND MATERIALS A retrospective chart review was conducted for all patients with cervical cancer who received single or multiple high-dose-rate brachytherapy implants between April 2006 and May 2017 at a single academic institution. CT and MRI images were retrospectively evaluated to record incidences of uterine perforation of tandem during brachytherapy. Acute and long-term complications during and after treatment were scored using the Common Terminology Criteria for Adverse Events, Version 4.0, of the National Cancer Institute. RESULTS A total of 123 patients were included in the study. Perforations were observed in 22 patients (17.9%) with 31 (6.4%) of the 482 total implants. Of the different categories of adverse events, only the rate of acute infectious complications among those with perforations (n = 3, 13.6%) versus those without perforations (n = 3, 3.0%) was significant (p = 0.040). Two of the three perforated patients with acute infections had mild urinary tract infections, and all resolved without complications or treatment delays. The remaining one patient had a frank perforation of the anterior uterine wall with a subsequent Grade 3 pyometra infection despite administration of prophylactic antibiotics and 1-week treatment delay. This case was eventually resolved with cervical dilation and evacuation of fluid. Long-term complications were not different between the two arms. CONCLUSIONS Patients with cervical cancer with uterine perforations may be able to safely proceed with brachytherapy treatment without delay or need for prophylactic antibiotics in the acute setting. Further validating data would be able to assist in establishing a new standard of care and help prevent unnecessary and harmful breaks during treatment.
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Affiliation(s)
- William Small
- Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL.
| | - Yo Sup Kim
- Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
| | - Cara Joyce
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
| | - Mark Leshyk
- Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
| | - Ronald K Potkul
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Margaret Liotta
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Abigail Winder
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Basel Altoos
- Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
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