Factors determining acute normal tissue reactions during postoperative radiotherapy in endometrial cancer: analysis of 317 consecutive cases

Incidence of radiation toxicity in cervical cancer and endometrial cancer patients treated with radiotherapy alone versus adjuvant radiotherapy

AIM

The study was made to evaluate early and late toxicity in a diversified group of patients receiving definitive or adjuvant radiotherapy in terms of clinical diagnosis and treatment methods.

BACKGROUND

Radiotherapy is a standard way of treatment in cervical and endometrial cancer patients, both as definitive and adjuvant therapy. But every radiation treatment may be involved with toxicity.

MATERIALS AND METHODS

A detailed analysis was performed of 263 patients with gynaecological cancer treated with definitive (90 patients with cervical cancer received radiochemotherapy or radiotherapy exclusively) and adjuvant radiotherapy (38 with cervical and 135 with endometrial cancer).

RESULTS

Acute reactions were found in 51.3% and late reactions were found in 14.8% of patients. It was stated that early (p < 0.007) and late (p < 0.003) post radiation reaction appear more frequently in women treated with definitive than adjuvant radiotherapy. The analysis of the whole group revealed higher rate of toxicity, both early and late, in the gastrointestinal tract than in the urinary system (p < 0.004). Comparing the subgroups, it was found that intestinal reactions occurred more frequently in the definitive radiotherapy group than in the adjuvant one. The occurrence of side effects was associated with the prolongation of total irradiation time due to necessary interruptions of radiotherapy. The comparison of the subgroups showed that interruptions occurred more frequently in patients receiving definitive rather than adjuvant radiotherapy (17.7-2.9%).

CONCLUSIONS

Definitive radiotherapy compared with adjuvant treatment may by associated with higher percentage of side effects caused by dose of therapy and correlation with chemotherapy.

Prophylactic vesical instillations with 0.2% chondroitin sulfate may reduce symptoms of acute radiation cystitis in patients undergoing radiotherapy for gynecological malignancies

Introduction and hypothesis

We studied the feasibility and efficacy of intravesical instillations with 40 ml chondroitin sulfate 0.2% solution to prevent or reduce acute radiation cystitis in women undergoing pelvic radiotherapy.

Methods

In a comparative pilot study in 20 patients, half of the patients received instillations. Instillations' bother was measured with visual analog scores (VAS, 0–10); bladder pain, with VAS; micturition-related quality of life, with the urogenital distress inventory (UDI).

Results

One of the instilled patients discontinued the instillations. The first median “acceptability”-VAS was 0 (range, 0–3); the last median was 1 (range, 0–3). “Bladder pain”-VAS peaked halfway in the treatment among controls (median, 1; range, 0–5) and after treatment in the instilled patients (median, 1; range, 1–3). UDI scores showed over time median follow-up scores at or above median baseline scores in controls and at or below median baseline scores in instilled patients.

Conclusion

Intravesical instillations with chondroitin sulfate 0.2% solution may decrease the bother related to bladder symptoms and are well tolerated.

Treatment effects, disease recurrence, and survival in obese women with early endometrial carcinoma

BACKGROUND

The objective was to examine whether rates of disease recurrence, treatment-related adverse effects, and survival differed between obese or morbidly obese and nonobese patients.

METHODS

Data from patients who participated in a randomized trial of surgery with or without adjuvant radiation therapy were retrospectively reviewed. RESULTS.: Body mass index (BMI) data were available for 380 patients, of whom 24% were overweight (BMI, 25-29.9), 41% were obese (BMI, 30-39.9), and 12% were morbidly obese (BMI, > or =40). BMI did not significantly differ based on age, performance status, histology, tumor grade, myometrial invasion, or lymphovascular-space involvement. BMI > 30 was more common in African Americans (73%) than non-African Americans (50%). Patients with a BMI > or = 40 compared with BMI < 30 (hazards ratio [HR], 0.42; 95% confidence interval [CI], 0.09-1.84; P = .246) did not have lower recurrence rates. Compared with BMI < 30, there was no significant difference in survival in patients with BMI 30-39.9 (HR, 1.48; 95% CI, 0.82-2.70; P = .196); however, there was evidence for decreased survival in patients with BMI > or = 40 (HR, 2.77; 95% CI, 1.21-6.36; P = .016). Unadjusted and adjusted BMI hazards ratios for African Americans versus non-African Americans in the current study differed, thus suggesting a confounding effect of BMI on race. Eight (67%) of 12 deaths among 45 morbidly obese patients were from noncancerous causes. For patients who received adjuvant radiation therapy, increased BMI was significantly associated with less gastrointestinal (R, -0.22; P = .003) and more cutaneous (R, 0.17; P = .019) toxicities.

CONCLUSIONS

In the current study, obesity was associated with higher mortality from causes other than endometrial cancer but not disease recurrence. Increased BMI was also associated with more cutaneous and less gastrointestinal toxicity in patients who received adjuvant radiation therapy. Future recommendations include lifestyle intervention trials to improve survival in obese endometrial cancer patients.

Treatment with a belly-board device significantly reduces the volume of small bowel irradiated and results in low acute toxicity in adjuvant radiotherapy for gynecologic cancer: results of a prospective study

BACKGROUND AND PURPOSE

To determine whether treatment prone on a belly-board significantly reduces the volume of small bowel irradiated in women receiving adjuvant radiotherapy for gynecologic cancer, and to prospectively study acute small bowel toxicity using an accepted recording instrument.

MATERIAL AND METHODS

Thirty-two gynecologic patients underwent simulation with CT scanning supine and prone. Small bowel was delineated on every CT slice, and treatment was prone on the belly-board using 3-5 fields-typically Anterior, Right and Left Lateral, plus or minus Lateral Boosts. Median prescribed dose was 50.4 Gy and all treatments were delivered in 1.8 Gy fractions. Concomitant Cisplatin was administered in 13 patients with cervical carcinoma. Comparison of small bowel dose-volumes was made between supine and prone, with each subject acting as their own matched pair. Acute small bowel toxicity was prospectively measured using the Common Toxicity Criteria: Version 2.0.

RESULTS

Treatment prone on the belly-board significantly reduced the volume of small bowel receiving > or = 100; > or = 95; > or = 90; and > or = 80% of the prescribed dose, but not > or = 50%. This was found whether volume was defined in cubic centimeters or % of total small bowel volume. Of 29 evaluable subjects, 2 (7%) experienced 1 episode each of grade 3 diarrhoea. All other toxicity events were grade 2 or less and comprised diarrhoea (59%), abdominal pain or cramping (48%), nausea (38%), anorexia (17%), vomiting (10%). There were no Grade 4 events and no treatment days were lost due to toxicity.

CONCLUSIONS

Treatment prone on a belly-board device results in significant small bowel sparing, during adjuvant radiotherapy for gynecologic cancer. The absence of Grade 4 events or Treatment Days Lost compares favorably with the published literature.

Time without symptoms and toxicity (TWIST) analysis of adjuvant radiation therapy for endometrial cancer

BACKGROUND AND PURPOSE

Postoperative radiotherapy in endometrial cancer reduces the risk of local relapse but is also associated with substantial acute and late reactions. The aim of our study was to evaluate time without tumor symptoms and toxicity (TWIST) in a consecutive series of 317 endometrial cancer patients administered postoperative irradiation.

PATIENTS AND METHODS

Both low-dose rate brachytherapy (BRT) and external beam irradiation (EBRT) were applied in 247 patients (78%), only BRT--in 49 (15%) and only EBRT--in 21 patients (7%). Median follow-up was 7.3 years (range, 4-21 years). TWIST analysis based on actuarial freedom from recurrent disease and from late radiotherapy effects was performed with the use of Kaplan-Meier method. The impact of patient- and treatment-related factors on TWIST was assessed with uni- and multivariate tests.

RESULTS

Five-year overall survival was 78%, and five-year disease free survival--75%. Recurrence occurred in 70 patients (22%), of whom in 11 (3.5%)--exclusively in the pelvis. Acute and late reactions of any grade occurred in 268 (85%) and 158 patients (51%), respectively. Late bowel effects of any grade were observed in 41% of patients. Severe late effects occurred in 35 patients (11%). Actuarial probability of two- and five-year survival free of disease and severe (grades 3 or 4) late effects (TWIST) was 84% and 71%, respectively (median TWIST, 16.2 years). When all-grade late effects were considered, two- and five-year TWIST probability was 50 and 30%, respectively, and median TWIST was only 2.0 years. When both acute and late reactions were taken into account, median TWIST was 22 months. In unifactorial test, higher age ( P = 0.013) FIGO stage ( P < 0.001) total radiotherapy dose ( P < 0.001) normalized total dose based on linear-quadratic model ( P = 0.001) EBRT fraction dose ( P < 0.001) and use of cesium BRT ( P = 0.042) were correlated with shorter TWIST. In multifactorial analysis, higher age ( P = 0.001) FIGO stage ( P = 0.001) and total radiotherapy dose ( P < 0.001) were independent factors correlated with shorter TWIST.

CONCLUSIONS

Endometrial cancer patients treated with postoperative irradiation have a long time interval without relapse and severe late toxicity. However, when any late normal tissue injury is considered, the median time without relapse and late toxicity is significantly shorter. The impact of mild late radiotherapy complications on the quality of life should be further investigated. TWIST calculation should be attempted in future prospective studies evaluating the role of postoperative radiotherapy.