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Wu CY, Tseng LM, Chen HH, Hsieh CH, Hsiao SM. Fatal rectovaginal fistula in post-radiotherapy locally advanced cervical cancer patients. Taiwan J Obstet Gynecol 2022; 61:1069-1072. [DOI: 10.1016/j.tjog.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 11/23/2022] Open
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2
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Wan Q, Yan W, Liu Y, Lin Y, Lu Z. Prognostic value of post-radiation serum squamous cell carcinoma antigen and primary tumor regression for cervical squamous cell carcinoma. Cancer Biomark 2021; 29:327-335. [PMID: 32716344 DOI: 10.3233/cbm-190934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In this study, we determined the prognostic values of magnetic resonance imaging (MRI)-based primary tumor regression and serum squamous cell carcinoma antigen (SSCC-Ag) levels 4 weeks after definitive radiotherapy (RT) in cervical squamous cell carcinoma (CSCC) patients. METHODS This was a retrospective study involving 218 patients with histologically confirmed CSCC (stages IB-IVA). All the patients received definitive RT. Pre- and post-RT pelvic MRI and SSCC-Ag levels were measured. Locoregional control (LRC), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated, and possible OS prognostic factors were analyzed. RESULTS The median follow-up time was 25.57 (1.73-58.93) months. Thirty-six and 68 patients died and experienced recurrence, respectively, and the primary tumors of 130 (59.6%) and 88 (40.4%) patients exhibited complete response (CR) and non-CR, respectively. The 3-year OS, DFS, LRC, and DMFS rates were significantly higher in the CR than in the non-CR patients (85.2% vs. 67.9%, 78.9% vs. 39.0%, 93.4% vs. 63.8%, and 83.4% vs. 54.5%, respectively; p< 0.05). The 3-year OS, DFS, LRC, and DMFS rates were significantly lower in the patients with high post-RT SSCC-Ag levels than in those with low post-RT SSCC-Ag levels (38.0% vs. 83.9%, 21.2% vs. 66.3%, 73.0% vs. 84.9%, and 26.5% vs. 79.0%, respectively; p<0.05). Multivariate analyses indicated that SSCC-Ag levels were an independent OS predictor (HR: 5.749, 95% CI: 2.598-12.723, p< 0.001). CONCLUSION Post-RT SSCC-Ag levels are OS independent prognostic factors in CSCC patients receiving RT. Timely and optimized treatment plans for CSCC patients after 4 weeks of RT are necessary when patients with persistent tumor and/or positive SSCC-Ag.
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Affiliation(s)
- Quan Wan
- Department of Oral and Maxillofacial Surgery, Stomatology Medical Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China.,Department of Oral and Maxillofacial Surgery, Stomatology Medical Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Wangxiang Yan
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Department of Oral and Maxillofacial Surgery, Stomatology Medical Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Yonghong Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Oral and Maxillofacial Surgery, Stomatology Medical Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Yanzhu Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Zhiyuan Lu
- Department of Oral and Maxillofacial Surgery, Stomatology Medical Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
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Jia AY, Viswanathan AN. Vaginal necrosis: A rare late toxicity after radiation therapy. Gynecol Oncol 2020; 160:602-609. [PMID: 33303211 DOI: 10.1016/j.ygyno.2020.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/23/2020] [Indexed: 01/22/2023]
Abstract
Vaginal necrosis is a late radiation tissue injury with serious morbidity complications. It is rare, and its incidence is not well assessed in prospective trials. Patient comorbidities and radiation dose can significantly increase the risk. As treatment of gynecologic malignancies often involve a multidisciplinary approach, timely diagnosis and appropriate management by physicians of the team are crucial. Untreated vaginal necrosis can lead to infection, hemorrhage, necrosis-related fistulation to the bladder or rectum, perforation, and death. In this review, we describe the pathophysiology of vaginal necrosis, its clinical course, and management options.
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Affiliation(s)
- Angela Y Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, United States of America
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, United States of America.
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Placenta Accreta in a Woman with Childhood Uterine Irradiation: A Case Report and Literature Review. Case Rep Obstet Gynecol 2019; 2019:2452975. [PMID: 31781442 PMCID: PMC6875035 DOI: 10.1155/2019/2452975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/17/2019] [Accepted: 09/12/2019] [Indexed: 12/17/2022] Open
Abstract
The pregnancies of childhood cancer survivors who have received uterine irradiation are associated with a high risk of several obstetrical complications, including placenta accreta. The present case was a 26-year-old pregnant woman with a history of myelodysplastic syndrome treated with umbilical cord blood transplantation following chemotherapy and total body irradiation at the age of 10. Despite every possible measure to prevent preterm labor, uterine contractions became uncontrollable and a female infant weighing 892 g was vaginally delivered at 27+4 weeks of gestation. Under the postpartum ultrasonographic diagnosis of placenta accreta, we selected to leave the placenta in situ. Although emergency bilateral uterine artery embolization was required, complete resorption of the residual placenta was accomplished on the 115th day postpartum. Our experience highlighted the following points. (1) The expectant management of placenta accreta arising in an irradiated uterus may not only fulfill fertility preservation, but may also reduce possible risks associated with cesarean hysterectomy. (2) Due to extreme thinning of and a poor blood supply to the myometrium, reaching an antepartum diagnosis of placenta accreta in an irradiated uterus is difficult. (3) The recurrence of placenta accreta in subsequent pregnancies needs to be considered after successful preservation of the uterus.
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George R, Prasoona TS, Kandasamy R, Mani T, Murali S, Rekha R, Muliyil J. Regular Low-Dose Oral Metronidazole Is Associated With Fewer Vesicovaginal and Rectovaginal Fistulae in Recurrent Cervical Cancer: Results From a 10-Year Retrospective Cohort. J Glob Oncol 2019; 5:1-10. [PMID: 31479340 PMCID: PMC6733185 DOI: 10.1200/jgo.19.00206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2019] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Anaerobic necrosis in cervical cancer can lead to malodor, fistulae, and treatment abandonment. In this retrospective cohort study, we examined the association between maintenance metronidazole and the incidence of malignant fistulae in recurrent cervical cancer. METHODS We screened all cervical cancer records registered between 2007 and 2016 in the local palliative care database at Christian Medical College, Vellore, India. There were 208 eligible patients with post-treatment residual/recurrent pelvic disease. Among them, 76 had received oral maintenance metronidazole 200 mg once per day for 2 to 86 weeks (interquartile range, 4-16 weeks). RESULTS Seventy-two patients developed at least one fistula. Forty-nine had vesicovaginal fistulae, 10 had rectovaginal fistuale, and 13 developed both types of fistulae. Patients on maintenance metronidazole had fewer fistulae (22.4% v 41.7%; P = .005), a longer median fistula-free survival (42.9 months v 14.1 months; P < .001), and a postrecurrence survival of 11.5 months versus 8.7 months (P = .112). We performed Cox multivariable proportional hazards regression analysis on the data from the subset of 146 patients observed until death. Bladder/rectal infiltration had a higher risk of fistula (HR, 5.24; P = .011), whereas distant metastases (HR, 2.46; P = .012) and Eastern Cooperative Oncology Group performance status greater than 1 (HR, 1.64; P = .008) were associated with a higher risk of death. Maintenance metronidazole was associated with a lower risk of fistula (hazard ratio [HR], 0.33; 95% CI, 0.16 to 0.67; P = .002) and a lower risk of death (HR, 0.56; 95% CI, 0.39 to 0.81; P = .002). CONCLUSION Our data indicate that there is a significant inverse association between oral maintenance metronidazole and malignant fistulae in locally recurrent cervical cancer. The impact of this simple intervention on pelvic symptoms, fistulae, and survival should be evaluated in prospective studies.
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Affiliation(s)
| | | | | | | | | | - Roja Rekha
- Christian Medical College, Vellore, India
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Tian Z, Yen A, Zhou Z, Shen C, Albuquerque K, Hrycushko B. A machine-learning-based prediction model of fistula formation after interstitial brachytherapy for locally advanced gynecological malignancies. Brachytherapy 2019; 18:530-538. [PMID: 31103434 DOI: 10.1016/j.brachy.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE External beam radiotherapy combined with interstitial brachytherapy is commonly used to treat patients with bulky, advanced gynecologic cancer. However, the high radiation dose needed to control the tumor may result in fistula development. There is a clinical need to identify patients at high risk for fistula formation such that treatment may be managed to prevent this toxic side effect. This work aims to develop a fistula prediction model framework using machine learning based on patient, tumor, and treatment features. METHODS AND MATERIALS This retrospective study included 35 patients treated at our institution using interstitial brachytherapy for various gynecological malignancies. Five patients developed rectovaginal fistula and two developed both rectovaginal and vesicovaginal fistula. For each patient, 31 clinical features of multiple data types were collected to develop a fistula prediction framework. A nonlinear support vector machine was used to build the prediction model. Sequential backward feature selection and sequential floating backward feature selection methods were used to determine optimal feature sets. To overcome data imbalance issues, the synthetic minority oversampling technique was used to generate synthetic fistula cases for model training. RESULTS Seven mixed data features were selected by both sequential backward selection and sequential floating backward selection methods. Our prediction model using these features achieved a high prediction accuracy, that is, 0.904 area under the curve, 97.1% sensitivity, and 88.5% specificity. CONCLUSIONS A machine-learning-based prediction model of fistula formation has been developed for patients with advanced gynecological malignancies treated using interstitial brachytherapy. This model may be clinically impactful pending refinement and validation in a larger series.
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Affiliation(s)
- Zhen Tian
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Allen Yen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Zhiguo Zhou
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Chenyang Shen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brian Hrycushko
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX.
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7
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Risk factors for fistula formation after interstitial brachytherapy for locally advanced gynecological cancers involving vagina. J Contemp Brachytherapy 2018; 10:510-515. [PMID: 30662473 PMCID: PMC6335549 DOI: 10.5114/jcb.2018.80171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/10/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To determine risk factors for fistula formation after interstitial brachytherapy (ISBT) in patients with advanced gynecologic cancers. Material and methods We performed an Institutional Review Board (IRB) approved retrospective review of 44 patients treated with transperineal template-based ISBT from 2011 to 2017 at a major metropolitan county and university health system. All patients were treated with image-guided high-dose-rate ISBT. Statistical analysis was performed using the χ2 test to identify factors correlated with fistula formation. Survival and tumor control outcomes were calculated using Kaplan Meier analyses. Results Patients had a mean age of 53 years (range, 28-81 years), a mean external beam dose of 43.1 Gy (range, 42.5-51.3 Gy), and a mean brachytherapy dose of 22.8 Gy (range, 21.3-30 Gy). Two of 44 patients had fistulas that could be definitively attributed to therapy for a fistula rate of 4.5%. Six additional patients (13.6%) developed fistula after treatment with associated recurrent disease but were included in the causality analysis. We analyzed patient tumor and treatment factors, and on univariate analyses we found that age ≥ 60 years, Hispanic ethnicity, bladder involvement, rectal D2 cc ≥ 70 Gy, and whether patients had post-radiation biopsies were predictors for fistula formation. The 1-year overall survival (OS), progression-free survival (PFS), and local control (LC) were 85%, 58.5%, and 76.9%, respectively, with a mean follow-up time 23 months (range, 4.0-68.8 months). Conclusions We identified factors that predict fistula formation in patients with advanced gynecologic tumors treated with ISBT. These factors can be used to stratify patients into a high-risk group, with potential for modification of brachytherapy planning to reduce their risk of fistula formation.
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Kalash R, Glaser SM, Rangaswamy B, Horne ZD, Kim H, Houser C, Beriwal S. Use of Functional Magnetic Resonance Imaging in Cervical Cancer Patients With Incomplete Response on Positron Emission Tomography/Computed Tomography After Image-Based High-Dose-Rate Brachytherapy. Int J Radiat Oncol Biol Phys 2018; 102:1008-1013. [DOI: 10.1016/j.ijrobp.2018.01.092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 11/15/2022]
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Iwamuro M, Hasegawa K, Hanayama Y, Kataoka H, Tanaka T, Kondo Y, Otsuka F. Enterovaginal and colovesical fistulas as late complications of pelvic radiotherapy. J Gen Fam Med 2018; 19:166-169. [PMID: 30186729 PMCID: PMC6119788 DOI: 10.1002/jgf2.184] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 04/24/2017] [Indexed: 12/31/2022] Open
Abstract
A 72-year-old Japanese woman presented with a fever, diarrhea, intermittent spotting, and constant fluid discharge from the vagina. Imaging studies revealed an enterovaginal fistula. She underwent radical hysterectomy and radiotherapy 35 years previously. She also had a surgical history of nephrostomy, nephrectomy, ileoascending anastomosis, and colostomy. As bleeding from the enterovaginal fistula was uncontrollable, ileocecal resection was performed. However, a colovesical fistula with urinary tract infection occurred 3 months later. The present case indicates that fistula formation occurs and causes various symptoms in patients who underwent postpelvic radiotherapy, particularly in those with prior surgeries in the irradiated field.
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Affiliation(s)
- Masaya Iwamuro
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kou Hasegawa
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Yoshihisa Hanayama
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hitomi Kataoka
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Takehiro Tanaka
- Department of PathologyOkayama University HospitalOkayamaJapan
| | - Yoshitaka Kondo
- Department of Gastroenterological SurgeryOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Fumio Otsuka
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
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Zelga P, Tchórzewski M, Zelga M, Sobotkowski J, Dziki A. Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies-new patients, old problem? Langenbecks Arch Surg 2017; 402:1079-1088. [PMID: 27987097 PMCID: PMC5660831 DOI: 10.1007/s00423-016-1539-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 12/08/2016] [Indexed: 01/15/2023]
Abstract
PURPOSE Radiation-induced rectovaginal fistula (RI-RVF) is a chronic and serious condition with a significant influence on quality of life. The aim of this study is to evaluate the results of surgical treatment of rectovaginal fistulas of patients previously undergoing radiotherapy. METHODS Fifty patients treated in the Gynaecological Radiotherapy Unit for gynaecologic malignancy and in the Department of General and Colorectal Surgery for RI-RVF between 2003 and 2013 were enrolled into a prospectively maintained database and underwent regular follow-up examinations in an outpatient clinic, during which surgical outcomes were assessed. RESULTS Median age was 60 years (range 40-84 years). Cervical cancer was the most common cause of radiotherapy. Median time of fistula development after radiotherapy was 20 months (range 5-240 months). In 48 (96%) patients, only faecal diversion could be performed, while two patients underwent rectal resection. The fistula healed in six patients. Factors that correlated with fistula healing were a distance from the anal verge above 7 cm (p = 0.007 OR 18 95%CI 2.2609-14.3062) and creation of loop ileostomy (p = 0.08 OR 17 95%CI 1.2818-23.9701), whereas a prolonged course of radiotherapy of more than 6 weeks (p = 0.047) correlated negatively. In multivariate analysis, only distance from the anal verge remained significant (p = 0.031 OR 2.35 95%CI 1.0422-5.2924). CONCLUSIONS The treatment of radiation-induced rectovaginal fistulas needs to be tailored individually to each patient. Faecal diversion remains the simplest and safest method of treating RI-RVF, especially in the group of patients who cannot undergo complicated surgical procedures, and offers acceptable quality of life.
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Affiliation(s)
- Piotr Zelga
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647 Lodz, Poland
| | - Marcin Tchórzewski
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647 Lodz, Poland
| | - Marta Zelga
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647 Lodz, Poland
| | - Janusz Sobotkowski
- Brachytherapy Unit, Regional Oncological Centre in Lodz, Pabianicka 62, Lodz, Poland
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647 Lodz, Poland
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Kamrava M, Beriwal S, Erickson B, Gaffney D, Jhingran A, Klopp A, Park SJ, Viswanathan A, Yashar C, Lin L. American Brachytherapy Society recurrent carcinoma of the endometrium task force patterns of care and review of the literature. Brachytherapy 2017; 16:1129-1143. [PMID: 28888417 DOI: 10.1016/j.brachy.2017.07.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/16/2017] [Accepted: 07/18/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this American Brachytherapy Society task force is to present a literature review and patterns of care by a panel of experts for the management of vaginal recurrence of endometrial cancer. METHODS AND MATERIALS In 2016, the American Brachytherapy Society Board selected a panel of experts in gynecologic brachytherapy to update our current state of knowledge for managing vaginal recurrence of endometrial cancer. Practice patterns were evaluated via an online survey and clinical updates occurred through a combination of literature review and clinical experience and/or expertise. RESULTS There are various retrospective series of patients treated with radiation for vaginal recurrence of endometrial cancer, which include a varied group of patients, multiple treatment techniques, and a range of total doses and demonstrate a wide scope of local control and overall survival outcomes. In the era of image-guided brachytherapy, high local control rates with low significant late-term morbidities can be achieved. Lower rates of local control and higher late-term toxicity are reported in the retreatment setting. In patients with no previous history of radiation treatment, external beam radiation therapy followed by brachytherapy boost should be used. There are varying practices with regard to the definition and appropriate doses of both the high-risk clinical target volume and the intermediate-risk clinical target volume in the setting of vaginal recurrence of endometrial cancer. There are limited data to provide appropriate dose constraints for some organs at risk with the majority of guidance taken from the definitive cervical cancer literature. CONCLUSIONS A summary of literature and expert practice patterns for patient selection, dose recommendations, and constraints are provided as guidance for practitioners.
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Affiliation(s)
- Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - David Gaffney
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - Anuja Jhingran
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Sang June Park
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Akila Viswanathan
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, CA
| | - Lilie Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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Sturdza A, Hofmann S, Kranawetter M, Polterauer S, Grimm C, Krainer M, Kirisits C, Pötter R, Reinthaller A, Schwameis R. Increased genitourinary fistula rate after bevacizumab in recurrent cervical cancer patients initially treated with definitive radiochemotherapy and image-guided adaptive brachytherapy. Strahlenther Onkol 2017; 193:1056-1065. [PMID: 28721510 PMCID: PMC5696499 DOI: 10.1007/s00066-017-1178-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/22/2017] [Indexed: 01/15/2023]
Abstract
Background and purpose Patients with recurrent cervical cancer (RecCC) who received definitive radiochemotherapy including image-guided adaptive brachytherapy (IGABT) as primary treatment are currently treated in our institution with palliative intent by chemotherapy (CHT) combined with bevacizumab (BEV). We aim to evaluate the risk of gastrointestinal (GI)/genitourinary (GU) fistula formation in these patients. Materials and methods Data of 35 consecutive patients with RecCC treated initially with radiochemotherapy and IGABT were collected. Known and presumed risk factors associated with fistula formation were evaluated. Fistula rate was compared between patients receiving CHT or CHT+BEV. Results Of the 35 patients, 25 received CHT and 10 patients received CHT+BEV. Clinical characteristics were comparable. Fistulae were reported in 6 patients: two fistulae (8%) in the CHT group, four (40%) in the CHT+BEV group. GU fistula occurred in the CHT+BEV group only (3/4). Of these 6 patients with fistulae, 5 (83%) had undergone previous invasive procedures after the diagnosis of RecCC and 1 patient had undergone pelvic re-irradiation; 3/6 patients had developed a local recurrence. No other risk factors for fistula formation were identified. Conclusion In patients with RecCC after definitive radiochemotherapy including IGABT, the addition of BEV to CHT may increase the risk for GU fistula formation, particularly after invasive pelvic procedures. Future clinical studies are required to identify predictors for fistula formation to subsequently improve patient selection for the addition of BEV in the RecCC setting.
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Affiliation(s)
- Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer CenterVienna, Medical University of Vienna, Vienna, Austria
| | - Sandra Hofmann
- Department of general Gynecology and Gynecologic Oncology, Comprehensive Cancer Center Vienna, Medical University Vienna, Waehringer Strasse 18-20, Vienna, Austria
| | - Marlene Kranawetter
- Department of general Gynecology and Gynecologic Oncology, Comprehensive Cancer Center Vienna, Medical University Vienna, Waehringer Strasse 18-20, Vienna, Austria
| | - Stephan Polterauer
- Department of general Gynecology and Gynecologic Oncology, Comprehensive Cancer Center Vienna, Medical University Vienna, Waehringer Strasse 18-20, Vienna, Austria.
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria.
| | - Christoph Grimm
- Department of general Gynecology and Gynecologic Oncology, Comprehensive Cancer Center Vienna, Medical University Vienna, Waehringer Strasse 18-20, Vienna, Austria
| | - Michael Krainer
- Clinical Division of Oncology, Department of Medicine 1, Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer CenterVienna, Medical University of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer CenterVienna, Medical University of Vienna, Vienna, Austria
| | - Alexander Reinthaller
- Department of general Gynecology and Gynecologic Oncology, Comprehensive Cancer Center Vienna, Medical University Vienna, Waehringer Strasse 18-20, Vienna, Austria
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - Richard Schwameis
- Department of general Gynecology and Gynecologic Oncology, Comprehensive Cancer Center Vienna, Medical University Vienna, Waehringer Strasse 18-20, Vienna, Austria
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Vargo JA, Viswanathan AN, Erickson BA, Beriwal S. Gynecologic Brachytherapy: Cervical Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_15] [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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14
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Yang J, Ding C, Zhang T, Zhang L, Lv T, Ge X, Gong J, Zhu W, Li N, Li J. Clinical features, outcome and risk factors in cervical cancer patients after surgery for chronic radiation enteropathy. Radiat Oncol 2015; 10:128. [PMID: 26047616 PMCID: PMC4462117 DOI: 10.1186/s13014-015-0433-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/28/2015] [Indexed: 11/10/2022] Open
Abstract
Background Radical hysterectomy and radiotherapy have long been mainstays of cervical cancer treatment. Early stage cervical cancer (FIGO stage IB1–IIA) is traditionally treated using radical surgery combined with radiotherapy, while locally advanced cervical cancer is treated using radiotherapy alone or chemoradiotherapy. In this retrospective study, we describe and analyse the presenting clinical features and outcomes in our cohort and evaluate possible risk factors for postoperative morbidity in women who underwent surgery for chronic radiation enteropathy (CRE). Methods One hundred sixty-six eligible cervical cancer patients who underwent surgery for CRE were retrospectively identified between September 2003 and July 2014 in a prospectively maintained database. Among them, 46 patients received radical radiotherapy (RRT) and 120 received radical surgery plus radiotherapy (RS + RT). Clinical features, postoperative morbidity and mortality, and risk factors for postoperative morbidity were analysed. Results RS + RT group patients were more likely to present with RTOG/EORTC grade III late morbidity (76.1 % vs 92.5 %; p = 0.004), while RRT group patients tended to show RTOG/EORTC grade IV late morbidity (23.9 % vs 7.5 %; p = 0.004). One hundred forty patients (84.3 %) were treated with aggressive resection (anastomosis 57.8 % and stoma 26.5 %). Overall and major morbidity, mortality and incidence of reoperation in the RRT and RS + RT groups did not differ significantly (63 % vs 64.2 % [p = 1.000], 21.7 % vs 11.7 % [p = 0.137], 6.5 % vs 0.8 % [p = 0.065] and 6.5 % vs 3.3 % [p = 0.360], respectively). However, incidence of permanent stoma and mortality during follow-up was higher in the RRT group than in the RS + RT group (44.2 % vs 12.6 % [p = 0.000] and 16.3 % vs 3.4 % [p = 0.004], respectively). In multivariate analysis, preoperative anaemia was significantly associated with overall morbidity (p = 0.015), while severe intra-abdominal adhesion (p = 0.017), ASA grades III–V (P = 0.022), and RTOG grade IV morbidity (P = 0.018) were predicators of major morbidity. Conclusions Radiation-induced late morbidity tended to be severe in the RRT group with more patients suffering RTOG/EORTC grade IV morbidity, while there were no significant differences in postoperative morbidity, mortality and reoperation. Aggressive resection was feasible with acceptable postoperative outcomes. Severe intra-abdominal adhesion, ASA grades III–V and RTOG/EORTC grade IV late morbidity contributed significantly to major postoperative morbidity.
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Affiliation(s)
- Jianbo Yang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Chao Ding
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Tenghui Zhang
- Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Southern Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Liang Zhang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Tengfei Lv
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Xiaolong Ge
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Jianfeng Gong
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. .,Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Southern Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Weiming Zhu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
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Abstract
PURPOSE OF REVIEW To review current literature on the management of genitourinary fistulae, specifically, the techniques for diagnosis, timing to repair, surgical approach and recent advancements in surgical technique. RECENT FINDINGS Recent advancement in minimally invasive surgery has prompted surgeons to perform fistula repairs with laparoscopic or robotic-assisted laparoscopic techniques. Whereas there is a role for transabdominal fistula closure, the majority of fistulae are still best approached via a transvaginal route. SUMMARY Genitourinary fistulae from obstetric trauma have received increased attention and funding to treat and prevent this devastating condition in developing countries. Despite multiple classification systems, a standardized classification that accurately identifies predictors of successful repair is lacking. In industrialized nations, genitourinary fistulae are rare and are most frequently associated with pelvic surgery, pelvic radiation, cancer or trauma. Surgical techniques to repair these fistulae have shifted from transabdominal laparotomy to minimally invasive laparoscopic procedures. Vascularized tissue flaps can play an important role in successful closure of complex fistulae. Despite advancements in surgical technology, overarching principles of fistula closure remain. The majority of fistulae can be closed through a transvaginal approach, with a tension-free, watertight, multilayer closure.
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