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Sarwar A, Eminowicz G. Radiotherapy induced ureteric stenosis in locally advanced cervical cancer: A review of current evidence. Brachytherapy 2024; 23:387-396. [PMID: 38643044 DOI: 10.1016/j.brachy.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/25/2024] [Accepted: 03/13/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Concurrent chemo-radiation followed by high dose rate brachytherapy is the standard of care for locally advanced cervical cancer. The proximity of the ureters to the tumor volume risks ureteric stenosis. Here we outline the current understanding of radiotherapy induced ureteric stenosis in patients treated for cervical cancer, focusing on the incidence, risk factors, clinical consequences, and management. METHODS Searches on EMBASE, PubMed, Science Direct, and Google Scholar were performed for publications reporting on radiotherapy, cervix cancer and ureteric stenosis. Multi and single center, prospective/retrospective, cohort, and cross-sectional studies were included. RESULTS This narrative review identified key issues relevant to radiation induced ureteric stenosis in cervical cancer in the literature. Thirteen studies were evaluated, identifying crude and actuarial rates of ureteric stenosis of 0.3-13.5% and 1.5-4.4% (at 5 years) respectively. The risk of ureteric stenosis is highest in the first 5 years after radiotherapy but continues to occur at a rate of 0.15% per year. Risk factors including advanced FIGO stage, tumor size >5 cm and baseline hydronephrosis increase the incidence of ureteric stenosis. EQD2 doses of ≥ 77Gy were significantly associated with ≥grade 3 ureteric morbidity. The majority of patients were managed with nephrostomy +/- ureteric stent insertion, with some requiring ureteral reimplantation, urinary diversion or nephrectomy. CONCLUSIONS This review has identified multiple considerations, highlighting the need to identify patients highest at risk of ureteric stenosis. There is also a need to recognize ureters as organs at risk, record dose exposure, and apply dose constraints, all of which set the landscape for allowing dose optimization.
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Affiliation(s)
- Asma Sarwar
- University College London Hospitals, London, UK; University College London, London, UK.
| | - Gemma Eminowicz
- University College London Hospitals, London, UK; University College London, London, UK
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Liu L, Yu C, Sun F, Yang T, Wei D, Wang G, Li S, Liu J. Can preoperative ureteral stents reduce the incidence of ureteral stricture after radiotherapy in patients with cervical cancer? BMC Urol 2022; 22:106. [PMID: 35850859 PMCID: PMC9295481 DOI: 10.1186/s12894-022-01029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/13/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To determine the impact of preoperative stent placement on postradiotherapy stricture rate in patients with cervical cancer after radical resection. Methods This study was a retrospective analysis of data collected from 55 cervical cancer patients treated with radiotherapy between June 2016 and June 2020. Patients were divided into the stent and control groups. After 3 months, the stricture rate and the complications related to stent placement between the two groups were compared. Results There were 12 (46.2%) and 10 (34.5%) cases of ureteral stricture in the stent (n = 26) and control (n = 29) groups, respectively, three months after the end of radiotherapy. The incidence rates of ureter stricture in the two groups were not significantly different (P = 0.378). Moreover, there were 20 units (38.5%) and 15 units (25.9%) ureteral strictures in the stent and control groups, respectively. No significant difference in the incidence rates of ureteral strictures was found between the two groups (P = 0.157). There were 13 (50.0%) and 10 (34.5%) cases of ureteral stricture in the stent (n = 26) and control (n = 29) groups, respectively, six months after the end of the radiotherapy. The incidence rates of ureter stricture in the two groups were not significantly different (P = 0.244). Moreover, there were 21 units (40.4%) and 15 units (25.9%) ureteral strictures in the stent and control groups, respectively. No significant difference in the incidence rates of ureteral strictures was found between the two groups (P = 0.105). Complications related to stent placement such as urinary tract infections and bladder irritation were statistically significant (P = 0.006 and P = 0.036) between the two groups; while the other complications were not significantly different (P = 0.070, P = 0.092 and P = 0.586). Conclusions Ureteral stents may not reduce the incidence of ureteral stricture after radiotherapy in patients with cervical cancer. The stent needs to be replaced regularly, and the complications related to stent placement may occur at any time. Thus, preoperative stent placement should be cautious for the clinical management of cervical cancer patients treated with postoperative radiotherapy.
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Affiliation(s)
- Liang Liu
- Department of Urology, Hebei General Hospital, Shijiazhuang, China.,Department of Urology, Baoding NO.1 Central Hospital, Baoding, China
| | - Chunhong Yu
- Department of Medical Examination Center, Hebei General Hospital, Shijiazhuang, China
| | - Fuzhen Sun
- Department of Urology, Hebei General Hospital, Shijiazhuang, China
| | - Tao Yang
- Department of Urology, Hebei General Hospital, Shijiazhuang, China
| | - Dong Wei
- Department of Urology, Hebei General Hospital, Shijiazhuang, China
| | - Gang Wang
- Department of Urology, Hebei General Hospital, Shijiazhuang, China
| | - Shoubin Li
- Department of Urology, Hebei General Hospital, Shijiazhuang, China.
| | - Junjiang Liu
- Department of Urology, Hebei General Hospital, Shijiazhuang, China.
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Abtahi M, Gholami S, Nashi HHJ. High dose rate 192Ir versus high dose rate 60Co brachytherapy: an overview of systematic reviews of clinical responses of gynecological cancers from 1984 to 2020. Biomed Phys Eng Express 2021; 7:055022. [DOI: https:/doi.org/10.1088/2057-1976/ac1c52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
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Dayyani M, Hoseinian-Azghadi E, Miri-Hakimabad H, Rafat-Motavalli L, Abdollahi S, Mohammadi N. Radiobiological comparison between Cobalt-60 and Iridium-192 high-dose-rate brachytherapy sources: Part I-cervical cancer. Med Phys 2021; 48:6213-6225. [PMID: 34415623 DOI: 10.1002/mp.15177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 05/26/2021] [Accepted: 07/30/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE This study aimed to compare the biological effective doses (BEDs) to clinical target volume (CTV) and organs at risk (OARs) for cervical cancer patients treated with high-dose-rate (HDR) Iridium-192 (192 Ir) or Cobalt-60 (60 Co) brachytherapy (BT) boost and to determine if the radiobiological differences between the two isotopes are clinically relevant. METHODS Considering all radiosensitivity parameters and their reported variations, the BEDs to CTV and OARs during HDR 60 Co/192 Ir BT boost were evaluated at the voxel level. The anatomical differences between individuals were also taken into account by retrospectively considering 25 cervical cancer patients. The intrafraction repair, proliferation, hypoxia-induced radiosensitivity heterogeneity, relative biological effectiveness (RBE), and source aging dose-rate variation were also taken into account. The comparisons in CTV were performed based on equivalent uniform BED (EUBED). RESULTS Considering nominal parameters with no RBE correction, the CTV EUBEDs were almost similar with a median ratio of ∼1.00 (p < 0.00001), whereas RBE correction resulted in 3.9%-5.5% (p = 0.005, median = 4.8%) decrease for 60 Co with respect to 192 Ir. For OARs, the median values of D2cc (in EQD23 ) for 60 Co were lower than that of 192 Ir up to 9.2% and 11.3% (p < 0.00001) for nominal parameters and fast repair conditions, respectively. In addition, for a nominal value (reported range) of radiosensitive parameters, the CTV EUBED differences of up to 6% (5%-10%) were assessed for HDR-BT component. CONCLUSION The RBE values are the most important cause of discrepancies between the two sources. By comparing BED/EUBEDs to CTV and OARs between 60 Co and 192 Ir sources, this numerical study suggests that a dose escalation to ∼4% is feasible and safe while sparing well the surrounding normal tissues. This 4% dose escalation should be benchmarked with clinical evidences (such as the results of clinical trials) before it can be used in clinical practice.
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Affiliation(s)
- Mahdieh Dayyani
- Radiation Oncology Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
| | | | - Hashem Miri-Hakimabad
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Laleh Rafat-Motavalli
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Sara Abdollahi
- Medical Physics Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
| | - Najmeh Mohammadi
- Physics Department, Faculty of Science, Sahand University of Technology, Tabriz, Iran
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Abtahi M, Gholami S, Jassim HH. High dose rate 192Ir versus high dose rate 60Co brachytherapy: an overview of systematic reviews of clinical responses of gynecological cancers from 1984 to 2020. Biomed Phys Eng Express 2021; 7:055022. [PMID: 34375964 DOI: 10.1088/2057-1976/ac1c52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/10/2021] [Indexed: 12/24/2022]
Abstract
The Purpose. Radioisotope of192Iradium (192Ir) has a half-life (74 days) and is not easily accessible in developing countries. As a result, by the time source shipment clearance and the customs paperwork are completed, a large proportion of useful activity had already been decayed away. In fact,60Cobalt (60Co) remote afterloading systems are commercially available by many venders. As a result, it may well become an alternative source to192Ir and conform many of these challenges. The aim of this study is that to report clinical responses of different types of gynaecological cancers treated with high dose rate (HDR)192Ir and HDR60Co brachytherapy in order to check whether HDR60Co could be used as an alternative brachytherapy, source to HDR192Ir.Materials and Methods. A retrospective study of clinical responses of different types of gynaecological cancers, staged from I to IV according to recommendations of International Federation of Gynaecology and Obstetrics (FIGO), treated by brachytherapy alone, radiotherapy alone (combined brachytherapy and radiotherapy) and combined radiotherapy and chemotherapy (brachytherapy, radiotherapy and chemotherapy) between 1984 and December 2020 was conducted. The patients were treated with external beam radiotherapy 45-51 Gy boosted with HDR192Ir and HDR60Co afterloading brachytherapy of 18-30 Gy to point A.The results. The study scrutinized the data of 11086 patients with different types of gynaecological cancers. Most of the patients, 70 percent of them, were diagnosed with gynaecological cancers in stages II and III. For patients treated with192Ir brachytherapy source 5-years overall survival rate (OS), local control, 2-years, 5-years and 10-years disease free survival (DFS), complications of gastro-intestine (GI) and complications of genito-urinary (GU) were 63.5%, 92%, 72.6%, 64.07%, 43.75%, 3.9% and 5.92%, but for those treated with60Co they were 57.7%, 86.63%, 82.5%, 53.35%, 43.75%, 4.8% and 3.7%, respectively.Conclusions.The use of HDR60Co brachytherapy has the capacity to produce overall survival rate and disease control in patients with carcinoma of the gynaecology comparable to that reported for HDR192Ir brachytherapy. Currently, the toxicity and damage of the normal tissues and radiation-related second cancers are of a similar incidence to that of standard HDR192Ir brachytherapy. Source exchange frequency is not a serious concern because it requires less frequency of replacement, and commissioning can be accomplished within years; hence, replacing HDR192Ir with HDR60Co brachytherapy achieves significant cost saving. Therefore, we recommend that60Co source ought to be the first choice for low resource radiotherapy setting as it offers economic advantages over192Ir and have comparable clinical outcomes to that of192Ir source.
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Affiliation(s)
- M Abtahi
- Department of Medical Physics and Biomedical Engineering, Tehran University of Medical Sciences, Tehran, Iran
| | - S Gholami
- Radiation Oncology department, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - H H Jassim
- Department of Medical Physics and Biomedical Engineering, Tehran University of Medical Sciences, Tehran, Iran
- Najaf Health Directorate, Ministry of Health, Najaf, Iraq
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Kumar RV, Bhasker S. Obesity in patients with carcinoma cervix increases the risk of adverse events. Rep Pract Oncol Radiother 2020; 25:212-216. [DOI: 10.1016/j.rpor.2019.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 08/17/2019] [Accepted: 12/23/2019] [Indexed: 11/17/2022] Open
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Abstract
ObjectiveThe purpose of this study is to identify incidence of and factors associated with severe late toxicity in women treated with radiation for cervical cancer.Materials and MethodsAll patients with cervical cancer treated with radiation as primary or adjuvant therapy from 2005 to 2017 in a single academic institution were included. Records were reviewed for demographic information, Charlson Comorbidity Index, treatment details, toxicities, and outcomes. Patients with and those without severe late gastrointestinal toxicity (SLGIT), severe late genitourinary toxicity (SLGUT), or any SLGIT or SLGUT, defined as any toxicity (AT), were compared. Overall survival and progression-free survival were also compared.ResultsOf 179 patients identified, 21.2% had AT, 17.3% had SLGIT, and 10% had SLGUT. Estimated AT rate at 3 years was 24.2%. The mean duration of follow-up was 37 months (range, 3–146 months). Most patients (84.1%) received 3-dimensional conformal therapy, and 15.9% received intensity-modulated radiation therapy. Factors associated with AT were lower body mass index (24.9 vs 28.3, P = 0.043), white race (63.2% vs 44%, P = 0.035), and active tobacco smoking during treatment (59.5% vs 40.2%, P = 0.036). Any toxicity was not associated with 3-dimensional versus intensity-modulated radiation therapy planning, low-dose versus high-dose–rate brachytherapy or time to complete radiation treatment. Higher total cumulative radiation dose to clinical target volume was associated with SLGIT. Progression-free survival and overall survival were similar among patients with AT compared to those without toxicity.ConclusionsIn patients with cervical cancer, radiation toxicity is correlated with lower body mass index, white race, and smoking. Despite technologic advances in radiotherapy planning and delivery, toxicity remains high and interventions to reduce the burden of treatment are needed.
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Jensen NBK, Pötter R, Kirchheiner K, Fokdal L, Lindegaard JC, Kirisits C, Mazeron R, Mahantshetty U, Jürgenliemk-Schulz IM, Segedin B, Hoskin P, Tanderup K. Bowel morbidity following radiochemotherapy and image-guided adaptive brachytherapy for cervical cancer: Physician- and patient reported outcome from the EMBRACE study. Radiother Oncol 2018; 127:431-439. [PMID: 29880222 DOI: 10.1016/j.radonc.2018.05.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE This study describes late bowel morbidity prospectively assessed in the multi-institutional EMBRACE study on MRI-guided adaptive brachytherapy in locally advanced cervical cancer (LACC). MATERIALS/METHODS A total of 1176 patients were analyzed. Physician reported morbidity (CTCAE v.3.0) and patient reported outcome (PRO) (EORTC QLQ C30/CX24) were assessed at baseline and at regular follow-up. RESULTS At 3/5 years the actuarial incidence of bowel morbidity grade 3-4 was 5.0%/5.9%, including incidence of stenosis/stricture/fistula of 2.0%/2.6%. Grade 1-2 morbidity was pronounced with prevalence rates of 28-33% during follow-up. Diarrhea and flatulence were most frequently reported, significantly increased after 3 months and remained elevated during follow-up. Incontinence gradually worsened with time. PRO revealed high prevalence rates. Diarrhea ≥"a little" increased from 26% to 37% at baseline to 3 months and remained elevated, difficulty in controlling bowel increased from 11% to 26% at baseline to 3 months gradually worsening with time. Constipation and abdominal cramps improved after treatment. CONCLUSION Bowel morbidity reported in this large cohort of LACC patients was limited regarding severe/life-threatening events. Mild-moderate diarrhea, flatulence and incontinence were prevalent after treatment with PROs indicating a considerable and clinically relevant burden. Critical knowledge based on the extent and manifestation pattern of treatment-related morbidity will serve future patient management.
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Affiliation(s)
| | - Richard Pötter
- Department of Radiation Oncology, Medical University of Vienna, Austria
| | | | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | - Renaud Mazeron
- Department of Radiation Oncology, Gustave-Roussy, Villejuif, France
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | | | - Barbara Segedin
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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Kim HJ, Kim S, Ha SW, Wu HG. Are Doses to ICRU Reference Points Valuable for Predicting Late Rectal and Bladder Morbidity after Definitive Radiotherapy in Uterine Cervix Cancer? TUMORI JOURNAL 2018; 94:327-32. [DOI: 10.1177/030089160809400307] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background To evaluate whether doses or dose rates at International Commission on Radiation Units (ICRU) reference points are of value for predicting risks of late rectal and bladder morbidity in patients with uterine cervical cancer who have undergone external beam radiotherapy and intracavitary irradiation. Methods Late rectal complications and late bladder complications were evaluated in 54 patients who were treated by external beam radiotherapy followed by intracavitary irradiation between January 1996 and December 1999. External beam radiotherapy was delivered in 1.8 Gy daily fractions to a whole pelvis dose of 50.4 Gy followed by intracavitary irradiation at total point A doses ranging from 75 Gy to 85 Gy. Intracavitary irradiation was performed with dose rates of 0.5–0.7 Gy/h to point A in most patients, but 8 patients were treated at a higher dose rate (0.83–1.15 Gy/h) to shorten the hospitalization period. Biologically effective doses for the reference points were calculated using a linear quadratic model. Results Grade 3 rectal and bladder morbidity by Radiation Therapy Oncology Group (RTOG) criteria developed in 4 patients (7.4%) and 1 (1.9%), respectively. An age of >60 years (P = 0.01) and a total dose to the rectal reference point of ≥80 Gy (P = 0.03) were found to be correlated with a higher rate of rectal morbidity. Total dose (≥80 Gy), dose rate (≥0.75 Gy/h), and biologically effective doses (≥135 Gy3) at the bladder reference point were found to be significant factors for the development of late bladder morbidity. By multivariate analysis, age was identified as the only significant factor of late rectal complications, and biologically effective doses at the bladder reference point was the only significant factor of late bladder complications. Conclusions RTOG grade 3 late rectal and bladder morbidity developed in respectively 7.4% and 1.9% of the patients. The significant risk factors for late rectal and bladder morbidity were old age and biologically effective doses at the bladder reference point, respectively.
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Affiliation(s)
- Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
| | - Suzy Kim
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Sung Whan Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, South Korea
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Goldfarb RA, Fan Y, Jarosek S, Elliott SP. The burden of chronic ureteral stenting in cervical cancer survivors. Int Braz J Urol 2017; 43:104-111. [PMID: 27649113 PMCID: PMC5293390 DOI: 10.1590/s1677-5538.ibju.2016.0667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/23/2016] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Ureteral obstruction in cervical cancer occurs in up to 11% of patients, many of whom undergo ureteral stenting. Our aim was to describe the patient burden of chronic ureteral stenting in a population-based cohort by detailing two objectives: (1) the frequency of repeat procedures for ureteral obstruction; and, (2) the frequency of urinary adverse effects (UAEs) (e.g., lower urinary tract symptoms, flank pain). MATERIALS AND METHODS From SEER-Medicare, we identified 202 women who underwent ureteral stent placement prior to or following cervical cancer treatment. The frequency of repeat procedures and rate ratios were compared between treatment modalities. The rates and rate ratios of UAEs were compared between our primary cohort (stent + cervical cancer) and the following groups: no stent + cervical cancer, stent + no cancer, and no stent + no cancer. The "no cancer" group was drawn from the 5% Medicare sample. RESULTS 117/202 women (58%) underwent >1 stent procedure. The frequency of additional procedures was significantly higher in patients who received radiation as part of their treatment. UAEs were very common in women with stent + cancer. The rate of UTI was 190 (per 100 person-years), 67 for LUTS, 42 for stones, and 6 for flank pain. These rates were 3-10 fold higher than in the no stent + no cancer control group; rates were also higher than in the no stent + cancer and the stent + no cancer women. CONCLUSIONS The burden of disease associated with ureteral stents is higher than expected and urologists should be actively involved in stent management, screening for associated symptoms and offering definitive reconstruction when appropriate.
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Affiliation(s)
- Robert A Goldfarb
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yunhua Fan
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stephanie Jarosek
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
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Annede P, Seisen T, Klotz C, Mazeron R, Maroun P, Petit C, Deutsch E, Bossi A, Haie-Meder C, Chargari C, Blanchard P. Inflammatory bowel diseases activity in patients undergoing pelvic radiation therapy. J Gastrointest Oncol 2017; 8:173-179. [PMID: 28280621 DOI: 10.21037/jgo.2017.01.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Few studies with contradictory results have been published on the safety of pelvic radiation therapy (RT) in patients with inflammatory bowel disease (IBD). METHODS From 1989 to 2015, a single center retrospective analysis was performed including all IBD patients who received pelvic external beam radiation therapy (EBRT) or brachytherapy (BT) for a pelvic malignancy. Treatment characteristics, IBD activity and gastrointestinal (GI) toxicity were examined. RESULTS Overall, 28 patients with Crohn's disease (CD) (n=13) or ulcerative colitis (n=15) were included in the present study. Median follow-up time after irradiation was 5.9 years. Regarding IBD activity, only one and two patients experienced a severe episode within and after 6 months of follow-up, respectively. Grade 3/4 acute GI toxicity occurred in 3 (11%) patients, whereas one (3.6%) patient experienced late grade 3/4 GI toxicity. Only patients with rectal IBD location (P=0.016) or low body mass index (BMI) (P=0.012) experienced more severe IBD activity within or after 6 months following RT, respectively. CONCLUSIONS We report an acceptable tolerance of RT in IBD patients with pelvic malignancies. Specifically, a low risk of uncontrolled flare-up was observed.
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Affiliation(s)
- Pierre Annede
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Thomas Seisen
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Caroline Klotz
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
| | - Pierre Maroun
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
| | - Claire Petit
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Eric Deutsch
- Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France;; Department of Molecular Radiotherapy, University Paris-Sud, SIRIC SOCRATES, Faculté de Médecine, Le Kremlin-Bicetre, France
| | - Alberto Bossi
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Christine Haie-Meder
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France;; NRBC Department, Institut de Recherche Biomédicale des Armées, Bretigny-sur-Orge, France
| | - Pierre Blanchard
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
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Abstract
Objective Radiation is an integral part of the treatment of many pelvic tumors. The cellular death induced by radiotherapy (RT) benefits cancer control but can also result in adverse effects (AEs) on the organ being treated or those adjacent to it. RT for cancers of the pelvis (bladder, prostate, rectum, uterus or cervix) can result in AEs in the urinary tract. While the acute urinary AEs of pelvic RT are well described, late AEs are less well characterized. The burden of treatment for late AEs may be large given the prevalence of tumors in the pelvis and the high utilization of RT to treat them. Review For prostate cancer, grade 1 and 2 urinary AEs following external beam radiation therapy (EBRT) are reported to occur in 20-43% and 7-19%, respectively, with a follow up of 10 years. Three-year cumulative risk for grade ≥2 urinary AEs is 28-30%. Following brachytherapy (BT), rates of urinary AEs at 5 years are reported to be 36%, 24%, 6.2% and 0.1% for Radiation Therapy Oncology Group (RTOG) grade 1, 2, 3, and 4, respectively. For bladder cancer, with a median follow-up of 5 years, 7-12% of patients who receive RT experience urinary AEs of grade 3 or more. For cervical cancer, there remains a 0.25% per year risk of severe AEs for at least 25 years following RT, and ureteral stricture is a well-described AE. For endometrial cancer, severe urinary AEs are rare, but at 13 years of follow up, patients report a significantly worse quality of life with respect to urinary function. In rectal cancer, preoperative RT has a lower risk of AEs than postoperative RT, and few urinary AEs are reported in the literature. Conclusions Urinary AEs can manifest long after RT, and there is a paucity of studies describing rates of these long-term AEs. It is important that the possible complications of RT are recognized by providers and properly communicated to patients so that they are able to make informed decisions about their cancer treatment.
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Affiliation(s)
- Daniel Liberman
- Department of Urology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Brian Mehus
- Department of Urology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Sean P Elliott
- Department of Urology, University of Minnesota School of Medicine, Minneapolis, MN, USA
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Impact of obesity on treatment-related adverse events, disease recurrence, and survival in women with cervical carcinoma. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s13566-016-0243-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mallick S, Madan R, Julka PK, Rath GK. Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management. Asian Pac J Cancer Prev 2015; 16:5589-94. [DOI: 10.7314/apjcp.2015.16.14.5589] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ho Than MT, Munro Iii JJ, Medich DC. Dosimetric characterization of the M-15 high-dose-rate Iridium-192 brachytherapy source using the AAPM and ESTRO formalism. J Appl Clin Med Phys 2015; 16:5270. [PMID: 26103489 PMCID: PMC5690138 DOI: 10.1120/jacmp.v16i3.5270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 12/16/2014] [Accepted: 01/16/2015] [Indexed: 11/23/2022] Open
Abstract
The Source Production & Equipment Co. (SPEC) model M−15 is a new Iridium−192 brachytherapy source model intended for use as a temporary high‐dose‐rate (HDR) brachytherapy source for the Nucletron microSelectron Classic afterloading system. The purpose of this study is to characterize this HDR source for clinical application by obtaining a complete set of Monte Carlo calculated dosimetric parameters for the M‐15, as recommended by AAPM and ESTRO, for isotopes with average energies greater than 50 keV. This was accomplished by using the MCNP6 Monte Carlo code to simulate the resulting source dosimetry at various points within a pseudoinfinite water phantom. These dosimetric values next were converted into the AAPM and ESTRO dosimetry parameters and the respective statistical uncertainty in each parameter also calculated and presented. The M−15 source was modeled in an MCNP6 Monte Carlo environment using the physical source specifications provided by the manufacturer. Iridium−192 photons were uniformly generated inside the iridium core of the model M−15 with photon and secondary electron transport replicated using photoatomic cross‐sectional tables supplied with MCNP6. Simulations were performed for both water and air/vacuum computer models with a total of 4×109 sources photon history for each simulation and the in‐air photon spectrum filtered to remove low‐energy photons below δ=10%keV. Dosimetric data, including D(r,θ),gL(r),F(r,θ),Φan(r), and φ¯an, and their statistical uncertainty were calculated from the output of an MCNP model consisting of an M−15 source placed at the center of a spherical water phantom of 100 cm diameter. The air kerma strength in free space, SK, and dose rate constant, Λ, also was computed from a MCNP model with M−15Iridium−192 source, was centered at the origin of an evacuated phantom in which a critical volume containing air at STP was added 100 cm from the source center. The reference dose rate, D˙(r0,θ0)≡D˙(1cm,π/2), is found to be 4.038±0.064 cGy mCi−1 h−1. The air kerma strength, SK, is reported to be 3.632±0.086 cGy cm2 mCi−1 g−1, and the dose rate constant, Λ, is calculated to be 1.112±0.029 cGy h−1 U−1. The normalized dose rate, radial dose function, and anisotropy function with their uncertainties were computed and are represented in both tabular and graphical format in the report. A dosimetric study was performed of the new M−15Iridium−192 HDR brachytherapy source using the MCNP6 radiation transport code. Dosimetric parameters, including the dose‐rate constant, radial dose function, and anisotropy function, were calculated in accordance with the updated AAPM and ESTRO dosimetric parameters for brachytherapy sources of average energy greater than 50 keV. These data therefore may be applied toward the development of a treatment planning program and for clinical use of the source. PACS numbers: 87.56.bg, 87.53.Jw
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Elliott SP, Fan Y, Jarosek S, Chu H, Downs L, Dusenbery K, Geller MA, Virnig BA. Propensity-Weighted Comparison of Long-Term Risk of Urinary Adverse Events in Elderly Women Treated For Cervical Cancer. Int J Radiat Oncol Biol Phys 2015; 92:586-93. [PMID: 25890845 DOI: 10.1016/j.ijrobp.2015.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/14/2015] [Accepted: 02/12/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Cervical cancer treatment is associated with a risk of urinary adverse events (UAEs) such as ureteral stricture and vesicovaginal fistula. We sought to measure the long-term UAE risk after surgery and radiation therapy (RT), with confounding controlled through propensity-weighted models. METHODS AND MATERIALS From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women ≥66 years old with nonmetastatic cervical cancer treated with simple surgery (SS), radical hysterectomy (RH), external beam RT plus brachytherapy (EBRT+BT), or RT+surgery. We matched them to noncancer controls 1:3. Differences in demographic and cancer characteristics were balanced by propensity weighting. Grade 3 to 4 UAEs were identified by diagnosis codes plus treatment codes. Cumulative incidence was measured using Kaplan-Meier methods. The hazard associated with different cancer treatments was compared using Cox models. RESULTS UAEs occurred in 272 of 1808 cases (17%) and 222 of 5424 (4%) controls; most (62%) were ureteral strictures. The raw cumulative incidence of UAEs was highest in advanced cancers. UAEs occurred in 31% of patients after EBRT+BT, 25% of patients after RT+surgery, and 15% of patients after RH; however, after propensity weighting, the incidence was similar. In adjusted Cox models (reference = controls), the UAE risk was highest after RT+surgery (hazard ratio [HR], 5.07; 95% confidence interval [CI], 2.32-11.07), followed by EBRT+BT (HR, 3.33; 95% CI, 1.45-7.65), RH (HR, 3.65; 95% CI, 1.41-9.46) and SS (HR, 0.99; 95% CI, 0.32-3.01). The higher risk after RT+surgery versus EBRT+BT was statistically significant, whereas, EBRT+BT and RH were not significantly different from each other. CONCLUSIONS UAEs are common after cervical cancer treatment, particularly in patients with advanced cancers. UAEs are more common after RT, but these women tend to have the advanced cancers. After propensity weighting, the risk after RT was similar to that after surgery.
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Affiliation(s)
- Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, Minnesota.
| | - Yunhua Fan
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Stephanie Jarosek
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Haitao Chu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Levi Downs
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Melissa A Geller
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota
| | - Beth A Virnig
- Department of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota
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Yang L, Lv Y. Possible risk factors associated with radiation proctitis or radiation cystitis in patients with cervical carcinoma after radiotherapy. Asian Pac J Cancer Prev 2014; 13:6251-5. [PMID: 23464440 DOI: 10.7314/apjcp.2012.13.12.6251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Radiation proctitis and radiation cystitis are major complications for patients with cervical carcinoma following radiotherapy. In the present study, we aimed to determine the potential risk factors for the development of radiation proctitis and radiation cystitis after irradiation. A total of 1,518 patients with cervical carcinoma received external beam radiotherapy (EBRT) followed by high-dose-rate intracavitary brachytherapy (HDRICB) in our hospital. The incidences of radiation proctitis and radiation cystitis were recorded and associations with different factors (age, time period, tumor stage) were analyzed with χ2 (chi-squared) and Fisher exact tests. We found that 161 and 94 patients with cervical carcinoma were diagnosed with radiation proctitis and radiation cystitis, respectively, following radiotherapy. The prevalence of Grade I-II radiation proctitis or radiation cystitis was significantly lower than that of Grade III (radiation proctitis: 3.82% vs. 6.76%, P <0.05; radiation cystitis: 2.31% vs. 3.87%, P < 0.05) and was significantly enhanced in patients with late stage (IIIb) tumor progression compared to those in early stage (Ib, IIa) (P < 0.05). Moreover, the incidence of radiation proctitis and cystitis was not correlated with age or, time period following radiation, for each patient (P > 0.05). These observations indicate that a late stage of tumor progression is a potential risk factor for the incidence of radiation proctitis and cystitis in cervical carcinoma patients receiving radiotherapy.
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Affiliation(s)
- Lin Yang
- Department of Radiation Oncology, the First Affiliated Hospital of Anhui Medical University, Hefei, China.
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Gaudet M, Lim P, Yuen C, Zhang S, Spadinger I, Dubash R, Aquino-Parsons C. Comparative analysis of rectal dose parameters in image-guided high-dose-rate brachytherapy for cervical cancer with and without a rectal retractor. Brachytherapy 2014; 13:257-62. [PMID: 24480263 DOI: 10.1016/j.brachy.2014.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 12/18/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The objective of this study was to determine if use of a rectal retractor (RR) in high-dose-rate intracavitary brachytherapy for cervical cancer reduces rectal dose parameters. METHODS AND MATERIALS We reviewed data obtained from patients treated with intracavitary brachytherapy for cervical cancer with and without an RR. Treatment plans for each brachytherapy fraction were separated into two groups; R group with use of an RR and P group with use of vaginal packing. Dose-volume parameters for high-risk clinical target volume (HR-CTV), rectum, sigmoid, small bowel, and vaginal surface were collected for each fraction. Rectal D2cc and International Commission on Radiation Units & Measurements (ICRU) rectal point doses were compared between groups using Student's t tests. Predictors of higher rectal D2cc were determined by univariate and multivariate regression analyses. RESULTS Four hundred sixty-three brachytherapy fractions from 114 patients were used for analysis, 377 fractions with a RR (R group) and 86 with vaginal packing only (P group). Both groups were similar except for slightly higher mean HR-CTV and mean bladder volume in P group. Both mean ICRU rectal point dose (241.1 vs. 269.9 cGy, p = 0.006) and rectal D2cc (240.6 vs. 283.6 cGy, p < 0.001) were significantly higher in P group. Point A dose, HR-CTV, stage, and use of an RR were significant predictors of rectal D2cc on multivariate analysis. CONCLUSIONS Our data show that use of an RR leads to lower rectal dose parameters compared with vaginal packing. Further study is needed to determine if this will lead to less long-term toxicity.
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Affiliation(s)
- Marc Gaudet
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada; Département de radio-oncologie, CSSS de Gatineau-Hôpital de Gatineau, Gatineau, QC, Canada.
| | - Peter Lim
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada
| | - Conrad Yuen
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada
| | - Susan Zhang
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada
| | - Ingrid Spadinger
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada
| | - Rustom Dubash
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada
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Koukourakis GV, Miliadou A, Tsalafoutas I, Geli E, Sotiropoulou-Lontou A. Ultrasound-assisted endocavitary HDR-Ir192 brachytherapy for unresectable locally advanced uterine cervix carcinoma: retrospective analysis focusing the efficacy and tolerability. Clin Transl Oncol 2013; 15:154-9. [DOI: 10.1007/s12094-012-0901-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 05/21/2012] [Indexed: 11/29/2022]
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Kim TH, Kim JY, Sohn DK, Kim YJ, Lee YS, Moon SH, Kim SS, Kim DY. A prospective observational study with dose volume parameters predicting rectosigmoidoscopic findings and late rectosigmoid bleeding in patients with uterine cervical cancer treated by definitive radiotherapy. Radiat Oncol 2013; 8:28. [PMID: 23369265 PMCID: PMC3570440 DOI: 10.1186/1748-717x-8-28] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 01/20/2013] [Indexed: 12/03/2022] Open
Abstract
Purpose We assessed the value of dose-volumetric parameters predicting rectosigmoid mucosal changes (RMC) and late rectosigmoid complications (LRC). Methods Between January 2004 and February 2006, 77 patients with stage IB-IIIB cervical cancer underwent external beam radiotherapy and computed tomography (CT)-based intracavitary irradiation. Total dose to the rectal point and several dose-volumetric parameters for rectosigmoid colon (D20cc, D15cc, D10cc, D5cc, D2cc, D1cc, and D0.1cc , defined as the minimal doses received by the highest irradiated volumes of 20, 15, 10, 5, 2, 1, and 0.1 cc, respectively), were calculated using the equivalent dose in 2 Gy fractions (α/β = 3, Gy3). The RMC and LRC were graded by rectosigmoidoscopy and Radiation Therapy Oncology Group criteria every 6 months, respectively. Results Of 77 patients, 27 (35.1%) patients developed RMC ≥ score 3 and 22 (28.6 %) patients developed LRC ≥ grade 2. There was a positive correlation between RMC score and LRC grade (r = 0.728, p < 0.001). In multivariate analyses, D5cc, among the dose-volumetric parameters, was significant parameter for the risks of RMC ≥ score 3 and LRC ≥ grade 2 (p < 0.05). Conclusions D5cc may be a more reliable estimate than other dose-volumetric parameters for predicting the risk of RMC ≥ score 3 and LRC ≥ grade 2 in CT-based brachytherapy.
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Affiliation(s)
- Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, South Korea
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Roy S, Devleena, Maji T, Chaudhuri P, Lahiri D, Biswas J. Addition of gemcitabine to standard therapy in locally advanced cervical cancer: A randomized comparative study. Indian J Med Paediatr Oncol 2011; 32:133-8. [PMID: 22557778 PMCID: PMC3342718 DOI: 10.4103/0971-5851.92809] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The concurrent chemoradiotherapy for cervical cancer treatment is well accepted since 1999. This randomized, phase III trial aimed to observe if any improved outcome could be obtained capitalizing on the synergistic activity of gemcitabine, cisplatin, XRT. MATERIALS AND METHODS Stage IIB-IIIB, 18-70 years of age, KPS score ≥70, were randomized to control group and study group. Control group received cisplatin 40 mg/m(2) weekly with concurrent XRT, followed by brachytherapy and study group received gemcitabine 125 mg/m(2) weekly top of the same control group treatment. The primary end point was pathological response and toxicities along with patient compliance to treatment, late reactions, DFS and OS. Fifty patients were randomized between two arms. RESULTS The complete response in study and control arm was 96% and 88% respectively. Toxicities was significantly high in the study group compared to control group [leucopenia (P=0.015), skin reaction (P=0.03) and bleeding (P=0.019)]. Local recurrence rate: 8% in study arm, none in control arm. The distant failure prevailed in control arm (20% vs. 8%). On a median follow up of 21 months in control arm, the DFS was 73% whereas 83% in study arm in 16 months (P=0.69). OS in the study arm was 100% and 84.5% in the control arm (P=0.14). CONCLUSIONS If the toxicity can be managed adequately in the combination chemo radiation group, it may produce an improvement in response. Survival benefit can also be obtained by introducing gemcitabine to cisplatin as radio sensitizer.
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Affiliation(s)
- Sanjoy Roy
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Devleena
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Tapas Maji
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Prabir Chaudhuri
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Debarshi Lahiri
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Jaydip Biswas
- Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
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Long-term urinary adverse effects of pelvic radiotherapy. World J Urol 2010; 29:35-41. [PMID: 20959990 DOI: 10.1007/s00345-010-0603-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Accepted: 09/28/2010] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Radiation for tumors arising in the pelvis has been utilized for over a 100 years. Adverse effects (AEs) of radiotherapy (RT) continue to accumulate with time and are reported to show decades after treatment. The benefit of RT for pelvic tumors is well described as is their acute AEs. Late AEs are less well described. The burden of treatment for the late AEs is large given the high utilization of RT. REVIEW For prostate cancer, 37% of patients will receive radiation during the first 6 months after diagnosis. Low-and high-grade AEs are reported to occur in 20-43 and 5-13%, respectively, with a median follow-up of ~60 months. For bladder cancer, the grade 2 and grade 3 late AEs occur in 18-27 and 6-17% with a median follow-up of 29-76 months. For cervical cancer, the risk of low-grade AEs following radiation can be as high as 28%. High-grade AEs occur in about 8% at 3 years and 14.4% at 20 years or ~0.34% per year. Radiation AEs appear to be less common or at least less well studied after radiation for rectal and endometrial cancers. CONCLUSION Properly delineating the rate of long-term AEs after pelvic RT is instrumental to counseling patients about their options for cancer treatment. Further studies are needed that are powered to specifically evaluate long-term AEs.
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Kizer NT, Thaker PH, Gao F, Zighelboim I, Powell MA, Rader JS, Mutch DG, Grigsby PW. The effects of body mass index on complications and survival outcomes in patients with cervical carcinoma undergoing curative chemoradiation therapy. Cancer 2010; 117:948-56. [PMID: 20945318 DOI: 10.1002/cncr.25544] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 06/17/2010] [Accepted: 06/21/2010] [Indexed: 01/23/2023]
Abstract
BACKGROUND The effect of body mass index (BMI) on treatment outcomes for patients with locally advanced cervical carcinoma who receive definitive chemoradiation is unclear. METHODS The cohort in this study included all patients with cervical carcinoma (n = 404) who had stage IB(1) disease and positive lymph nodes or stage ≥IB(2) disease and received treatment at the authors' facility between January 1998 and January 2008. The mean follow-up was 47.2 months. BMI was calculated using the National Institute of Health online calculator. BMI categories were created according to the World Health Organization classification system. Primary outcomes were overall survival, disease-free survival, and complication rate. Univariate and multivariate analyses were performed. Kaplan-Meier survival curves were generated and compared using Cox proportional hazard models. RESULTS On multivariate analysis, compared with normal weight (BMI 18.5-24.9 kg/m(2) ), a BMI <18.5 kg/m(2) was associated with decreased overall survival (hazard ratio, 2.37; 95% confidence interval, 1.28-4.38; P < .01). The 5-year overall survival rate was 33%, 60%, and 68% for a of BMI <18.5 kg/m(2) , a BMI from 18.5 kg/m(2) to 24.9 kg/m(2) , and a BMI >24.9 kg/m(2) , respectively. A BMI <18.5 kg/m(2) was associated with increased risk of grade 3 or 4 complications compared with a BMI >24.9 kg/m(2) (radiation enteritis: 16.7% vs 13.6%, respectively; P = .03; fistula: 11.1% vs 8.8%, respectively; P = .05; bowel obstruction: 33.3% vs 4.4%, respectively; P < .001; lymphedema: 5.6% vs 1.2%, respectively; P = .02). CONCLUSIONS Underweight patients (BMI <18.5 kg/m(2) ) with locally advanced cervical cancer had diminished overall survival and more complications than normal weight and obese patients.
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Affiliation(s)
- Nora T Kizer
- Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Kato S, Tran DNL, Ohno T, Nakano T, Kiyohara H, Ohkubo Y, Kamada T. CT-based 3D dose-volume parameter of the rectum and late rectal complication in patients with cervical cancer treated with high-dose-rate intracavitary brachytherapy. JOURNAL OF RADIATION RESEARCH 2010; 51:215-221. [PMID: 20339256 DOI: 10.1269/jrr.09118] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This study evaluated the efficacy of computed tomography (CT)-based three-dimensional (3D) dose-volume parameters of the rectum as predictor for late rectal complication (LRC) in cervical cancer patients treated with radiotherapy alone. Eighty-four patients treated with a combination of external radiotherapy and high-dose-rate intracavitary brachytherapy between January 2000 and December 2004 were retrospectively analyzed. Brachytherapy was prescribed with standard 2D planning. Patients underwent pelvic CT at brachytherapy. The external rectal wall was contoured on the CT images, and the minimum doses delivered to 0.1cc, 1cc, and 2cc of the most irradiated rectal volumes were calculated with dose-volume histograms. The International Commission of Radiation Units and Measurements (ICRU) rectal point dose was also calculated by conventional method. Total dose (external radiotherapy plus brachytherapy) to the rectum was transformed to the biologically equivalent dose in 2-Gy fractions with alpha/beta of 3 Gy (D(0.1cc), D(1cc), D(2cc) and D(ICRU)). The relationships between these dosimetric parameters and the incidence of LRC were analyzed. The 5-year overall actuarial rate of LRC was 26.4%. The values of D(0.1cc), D(1cc), and D(2cc) were significantly higher in patients with LRC than in those without (p < 0.001), but the difference in the values of D(ICRU) was not statistically significant (p = 0.10). The rate of LRC increased significantly with increasing D(0.1cc), D(1cc), and D(2cc) (p = 0.001). However, no positive dose-response relationship was observed between D(ICRU) and the rate of LRC (p = 0.42). The present study has suggested that CT-based 3D dose-volume parameters of the rectum may be effective for predicting LRC.
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Affiliation(s)
- Shingo Kato
- Research Center Hospital for Charged Particle Therapy, National Institute of Radiological Sciences, Inage-ku, Chiba, 263-8555, Japan.
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Chen SW, Liang JA, Hung YC, Yeh LS, Chang WC, Yang SN, Lin FJ. Geometrical Sparing Factors for the Rectum and Bladder in the Prediction of Grade 2 and Higher Complications After High-Dose-Rate Brachytherapy for Cervical Cancer. Int J Radiat Oncol Biol Phys 2009; 75:1335-43. [DOI: 10.1016/j.ijrobp.2008.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 11/26/2008] [Accepted: 12/12/2008] [Indexed: 10/20/2022]
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Viani GA, Manta GB, Stefano EJ, de Fendi LI. Brachytherapy for cervix cancer: low-dose rate or high-dose rate brachytherapy - a meta-analysis of clinical trials. J Exp Clin Cancer Res 2009; 28:47. [PMID: 19344527 PMCID: PMC2673206 DOI: 10.1186/1756-9966-28-47] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 04/05/2009] [Indexed: 11/17/2022] Open
Abstract
Background The literature supporting high-dose rate brachytherapy (HDR) in the treatment of cervical carcinoma derives primarily from retrospective series. However, controversy still persists regarding the efficacy and safety of HDR brachytherapy compared to low-dose rate (LDR) brachytherapy, in particular, due to inadequate tumor coverage for stage III patients. Whether LDR or HDR brachytherapy produces better results for these patients in terms of survival rate, local control rate and the treatment complications remain controversial. Methods A meta-analysis of RCT was performed comparing LDR to HDR brachytherapy for cervix cancer treated for radiotherapy alone. The MEDLINE, EMBASE, CANCERLIT and Cochrane Library databases, as well as abstracts published in the annual proceedings were systematically searched. We assessed methodological quality for each outcome by grading the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. We used "recommend" for strong recommendations, and "suggest" for weak recommendations. Results Pooled results from five randomized trials (2,065 patients) of HDR brachytherapy in cervix cancer showed no significant increase of mortality (p = 0.52), local recurrence (p = 0.68), or late complications (rectal; p = 0.7, bladder; p = 0.95 or small intestine; p = 0.06) rates as compared to LDR brachytherapy. In the subgroup analysis no difference was observed for overall mortality and local recurrence in patients with clinical stages I, II and III. The quality of evidence was low for mortality and local recurrence in patients with clinical stage I, and moderate for other clinical stages. Conclusion Our meta-analysis shows that there are no differences between HDR and LDR for overall survival, local recurrence and late complications for clinical stages I, II and III. By means of the GRADE system, we recommend the use of HDR for all clinical stages of cervix cancer.
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Affiliation(s)
- Gustavo A Viani
- Radiation Oncology Department at Marilia School of Medicine, São Paulo, Brazil.
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Georg P, Kirisits C, Goldner G, Dörr W, Hammer J, Pötzi R, Berger D, Dimopoulos J, Georg D, Pötter R. Correlation of dose-volume parameters, endoscopic and clinical rectal side effects in cervix cancer patients treated with definitive radiotherapy including MRI-based brachytherapy. Radiother Oncol 2009; 91:173-80. [PMID: 19243846 DOI: 10.1016/j.radonc.2009.01.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2008] [Revised: 12/26/2008] [Accepted: 01/08/2009] [Indexed: 02/07/2023]
Abstract
PURPOSE Correlation of dosimetric parameters for MRI-based 3D treatment planning with rectoscopic findings and clinical rectal side effects. METHODS AND MATERIALS Rectosigmoidoscopy and rectal morbidity assessment were performed on 35 cervical cancer patients treated with external beam radiotherapy (EBRT) and HDR-intracavitary brachytherapy (ICB). The total doses, normalised to 2 Gy fractions (EQD2, alpha/beta=3 Gy), in 0.1, 1.0 and 2.0 cm(3) (D(0.1 cc), D(1 cc), D(2 cc)) of rectum were determined by summation of EBRT and ICB plans. Correlation analysis between clinical symptoms (LENT/SOMA) and rectoscopic changes (Vienna Rectoscopy Score, VRS) was performed. For dose-response analyses, the logit model was applied. RESULTS Mean follow-up was 18 months. LENT/SOMA score was 1 in 4 patients, 2 in 8 patients, 4 in 1 patient. Telangiectasia was found in 26 patients (74%), five of them had ulceration corresponding to the 0.1 cm(3) volume (anterior wall). Mean values D(0.1 cc), D(1 cc), and D(2 cc) were 81+/-13, 70+/-9 and 66+/-8 Gy, respectively. The ED50 values for VRS > or = 3 and for LENT/SOMA > or = 2 significantly increased with decreasing volumes. D(2 cc) was higher in patients with VRS > or = 3 compared to VRS<3 (72+/-6 vs 62+/-7 Gy; p<0.001) and in symptomatic vs asymptomatic patients (72+/-6 vs 63+/-8 Gy; p<0.001). VRS correlated with the LENT/SOMA score. CONCLUSIONS Rectosigmoidoscopy is sensitive in detecting mucosal changes, independent of clinical symptoms. The localization of these changes corresponds to the high dose volumes as defined by imaging. The development of mucosal and clinical changes in the rectum follows a clear dose-effect and volume-effect. DVH parameters could be established.
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Affiliation(s)
- Petra Georg
- Department of Radiotherapy, Medical University-Vienna, Vienna, Austria.
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Franckena M, Lutgens LC, Koper PC, Kleynen CE, van der Steen-Banasik EM, Jobsen JJ, Leer JW, Creutzberg CL, Dielwart MF, van Norden Y, Canters RAM, van Rhoon GC, van der Zee J. Radiotherapy and hyperthermia for treatment of primary locally advanced cervix cancer: results in 378 patients. Int J Radiat Oncol Biol Phys 2008; 73:242-50. [PMID: 18990505 DOI: 10.1016/j.ijrobp.2008.03.072] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 03/26/2008] [Accepted: 03/27/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE To report response rate, pelvic tumor control, survival, and late toxicity after treatment with combined radiotherapy and hyperthermia (RHT) for patients with locally advanced cervical carcinoma (LACC) and compare the results with other published series. METHODS AND MATERIALS From 1996 to 2005, a total of 378 patients with LACC (International Federation of Gynecology and Obstetrics Stage IB2-IVA) were treated with RHT. External beam radiotherapy (RT) was applied to 46-50.4 Gy and combined with brachytherapy. The hyperthermia (HT) was prescribed once weekly. Primary end points were complete response (CR) and local control. Secondary end points were overall survival, disease-specific survival, and late toxicity. Patient, tumor, and treatment characteristics predictive for the end points were identified in univariate and multivariate analyses. RESULTS Overall, a CR was achieved in 77% of patients. At 5 years, local control, disease-specific survival, and incidence of late toxicity Common Terminology Criteria for Adverse Events Grade 3 or higher were 53%, 47%, and 12%, respectively. In multivariate analysis, number of HT treatments emerged as a predictor of outcome in addition to commonly identified prognostic factors. CONCLUSIONS The CR, local control, and survival rates are similar to previously observed results of RHT in the randomized Dutch Deep Hyperthermia Trial. Reported treatment results for currently applied combined treatment modalities (i.e., RT with chemotherapy and/or HT) do not permit definite conclusions about which combination is superior. The present results confirm previously shown beneficial effects from adding HT to RT and justify the application of RHT as first-line treatment in patients with LACC as an alternative to chemoradiation.
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Affiliation(s)
- Martine Franckena
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
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Jewell EL, Kulasingam S, Myers ER, Alvarez Secord A, Havrilesky LJ. Primary surgery versus chemoradiation in the treatment of IB2 cervical carcinoma: A cost effectiveness analysis. Gynecol Oncol 2007; 107:532-40. [PMID: 17900674 DOI: 10.1016/j.ygyno.2007.08.056] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 08/07/2007] [Accepted: 08/08/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate the relative cost-effectiveness of treatments for patients with FIGO stage IB2 cervical cancer and no evidence of metastasis as determined by combination of positron emission tomography/computed tomography (PET/CT). METHODS A Markov state transition model was constructed to compare two strategies: (1) radical hysterectomy and pelvic lymphadenectomy with tailored adjuvant therapy (RH+TA); (2) primary chemoradiation (CR). Five-year survival estimates for FIGO stage IB2 cervical cancer were obtained from literature. Medicare reimbursement rates and Agency for Healthcare Research and Quality database were used to obtain costs of treatment regimens and grades 3-5 adverse events. Strategies were compared using incremental cost per year of life saved (YLS). Extensive sensitivity analyses were performed. RESULTS Overall survival estimates were 78.9% for CR; 79.6% for RH+TA. Mean cost for CR at 5 years was $21,403 compared to $27,840 for RH+TA. RH+TA cost $63,689 per additional year of life saved (YLS) compared to CR. Results were most sensitive to survival estimates and the costs associated with high dose rate (HDR) versus low dose rate (LDR) brachytherapy. If 90% of patients with intermediate pathologic risk factors at surgery were assumed to receive adjuvant CR, the ICER of RH+TA rose to $100,000 per YLS compared to CR. CONCLUSIONS RH+TA is potentially cost effective when compared to CR for patients with stage IB2 cervical cancer without metastatic disease by PET/CT imaging. Key factors in the cost-effectiveness of treatments include physician's expected recommendation of adjuvant therapy, brachytherapy modality employed for primary CR and quality of life related to both treatment and its complications.
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Affiliation(s)
- Elizabeth L Jewell
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Noda SE, Ohno T, Kato S, Ishii T, Saito O, Wakatsuki M, Tamaki T, Watanabe K, Nakano T, Tsujii H. Late Rectal Complications Evaluated by Computed Tomography–Based Dose Calculations in Patients With Cervical Carcinoma Undergoing High-Dose-Rate Brachytherapy. Int J Radiat Oncol Biol Phys 2007; 69:118-24. [PMID: 17513064 DOI: 10.1016/j.ijrobp.2007.02.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Revised: 02/10/2007] [Accepted: 02/15/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate the efficacy of dose calculations at the computed tomography (CT)-based rectal point (CTRP) as a predictive factor for late rectal complications in patients with cervical carcinoma who were treated with a combination of high-dose-rate intracavitary brachytherapy and external beam radiotherapy. METHODS AND MATERIALS Ninety-two patients with uterine cervical carcinoma undergoing definitive radiotherapy alone were retrospectively analyzed. The median follow-up time for all patients was 32 months (range, 13-60 months). The cumulative biologically effective dose (BED) was calculated at the rectal reference point as defined by the International Commission on Radiation Units and Measurements Report 38 (BED(RP)) and at the CTRP (BED(CTRP)). Late rectal complications were recorded according to the Radiation Therapy Oncology Group grading system. RESULTS The late rectal complications were distributed as follows: Grade 0, 68 patients (74%); Grade 1, 20 patients (22%); Grade 2, 4 patients (4%). Univariate analysis showed that BED(RP), BED(CTRP), RP dose/point A dose ratio, and CTRP dose/point A dose ratio were significantly correlated with late rectal complications (p < 0.05). On multivariate analysis, patients with a rectal BED(CTRP) >/=140 Gy(3) presented with significantly greater frequency of rectal complications (p = 0.031). CONCLUSIONS The present results suggest that BED(CTRP) is a useful predictive factor for late rectal complications.
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Affiliation(s)
- Shin-Ei Noda
- Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, Anagawa, Chiba, Japan
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31
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Medich DC, Munro JJ. Monte Carlo characterization of the M-19 high dose rate Iridium-192 brachytherapy source. Med Phys 2007; 34:1999-2006. [PMID: 17654903 DOI: 10.1118/1.2733809] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The MCNP5 Monte Carlo code was used to simulate the dosimetry of an M-19 iridium-192 high dose rate brachytherapy source in both air/vacuum and water environments with the in-air photon spectrum filtered to remove low-energy photons below delta=10 keV. Dosimetric data was organized into an away-along table and was used to derive the updated AAPM Task Group Report No. 43 (TG-43U1) parameters including S(K), D(r, theta), lamda, gL(r), F(r, theta), phi an(r), and phi an, and their respective statistical uncertainties.
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Affiliation(s)
- David C Medich
- Radiation Laboratory, University of Massachusetts Lowell, 1 University Avenue, Lowell, Massachusetts 01854, USA.
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Koom WS, Sohn DK, Kim JY, Kim JW, Shin KH, Yoon SM, Kim DY, Yoon M, Shin D, Park SY, Cho KH. Computed Tomography-Based High-Dose-Rate Intracavitary Brachytherapy for Uterine Cervical Cancer: Preliminary Demonstration of Correlation Between Dose–Volume Parameters and Rectal Mucosal Changes Observed by Flexible Sigmoidoscopy. Int J Radiat Oncol Biol Phys 2007; 68:1446-54. [PMID: 17482766 DOI: 10.1016/j.ijrobp.2007.02.009] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Revised: 01/31/2007] [Accepted: 02/01/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE To compare the dose-volume histogram (DVH) parameters obtained by three-dimensional gynecologic brachytherapy planning with the rectosigmoid mucosal changes observed by flexible sigmoidoscopy. METHODS AND MATERIALS Between January 2004 and July 2005, 71 patients with International Federation of Gynecology and Obstetrics Stage IB-IIIB uterine cervical cancer underwent computed tomography-based high-dose-rate intracavitary brachytherapy. The total dose (external beam radiotherapy [RT] plus intracavitary brachytherapy) to the International Commission of Radiation Units and Measurements rectal point (ICRU(RP)) and DVH parameters for rectosigmoid colon were calculated using the equivalent dose in 2-Gy fractions (alpha/beta = 3 Gy). Sigmoidoscopy was performed every 6 months after RT, with the 6-scale scoring system used to determine mucosal changes. RESULTS The mean values of the DVH parameters and ICRU(RP) were significantly greater in patients with a score of > or =2 than in those with a score <2 at 12 months after RT (ICRU(RP), 71 Gy(alpha/beta3) vs. 66 Gy(alpha/beta3), p = 0.02; D(0.1cc), 93 Gy(alpha/beta3) vs. 85 Gy(alpha/beta3), p = 0.04; D(1cc), 80 Gy(alpha/beta3) vs. 73 Gy(alpha/beta3), p = 0.02; D(2cc), 75 Gy(alpha/beta3) vs. 69 Gy(alpha/beta3), p = 0.02). The probability of a score of > or =2 showed a significant relationship with the DVH parameters and ICRU(RP) (ICRU(RP), p = 0.03; D(0.1cc), p = 0.05; D(1cc), p = 0.02; D(2cc), p = 0.02). CONCLUSION Our preliminary data have shown that DVH values of the rectosigmoid colon obtained by computed tomography-based three-dimensional brachytherapy planning are reliable and predictive of score > or =2 rectosigmoid mucosal changes.
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Affiliation(s)
- Woong Sub Koom
- Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, South Korea
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Saibishkumar EP, Patel FD, Sharma SC. Evaluation of Late Toxicities of Patients with Carcinoma of the Cervix Treated with Radical Radiotherapy: An Audit from India. Clin Oncol (R Coll Radiol) 2006; 18:30-7. [PMID: 16477917 DOI: 10.1016/j.clon.2005.06.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate the incidence of, and factors affecting, late toxicities of women with carcinoma of the cervix treated with radical radiotherapy. MATERIALS AND METHODS Between 1996 and 2001, 1069 women with carcinoma of the cervix (stage I-IVA) were treated at our centre with external-beam radiotherapy (EBRT) and intra-cavitary radiotherapy (ICRT) (n = 871) or EBRT alone (n = 198). Median follow-up was 34 months. Median dose to point A was 81 Gy. RESULTS Five-year actuarial incidence of overall (all grades) and severe (grade 3/4) late toxicities in the rectum, bladder, small intestine and subcutaneous tissue were 12.3% and 1.1%, 11.2% and 1.2%, 9.2% and 0.2%, and 23.1% and 1.2%, respectively. Vaginal adhesions were seen in 29.6% of cases and stenosis in 33.9% of cases. On multivariate analysis, factors adversely affecting overall incidence of proctitis were anterior-posterior (AP) separation of patient more than 18 cm and presence of comorbid diseases. Presence of comorbid diseases was the only factor affecting the incidence of severe proctitis (grade 3/4). AP separation more than 18 cm adversely affected the incidence of cystitis, both overall and severe. Late toxicities (all grades) in small bowel were increased in subsets, like women younger than 50 years and women with comorbid diseases, but no factor emerged as significant for incidence of severe toxicities. Subcutaneous fibrosis was significantly higher in patients with AP separation over 18 cm, those treated by cobalt machines and those who received EBRT only. Severe subcutaneous fibrosis was influenced by the use of EBRT alone. Overall incidence of vaginal toxicity was higher in women whose overall treatment time (OTT) was shorter and in women who received ICRT. Vaginal stenosis was higher in elderly women and in women who received ICRT by low dose rate. CONCLUSIONS Even with telecobalt machines, impressive results with acceptable late toxicity can be achieved in the treatment of cancer of the cervix using an ideal combination of EBRT with ICRT.
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Affiliation(s)
- E P Saibishkumar
- Department of Radiotherapy, Post-graduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Modesitt SC, van Nagell JR. The impact of obesity on the incidence and treatment of gynecologic cancers: a review. Obstet Gynecol Surv 2006; 60:683-92. [PMID: 16186785 DOI: 10.1097/01.ogx.0000180866.62409.01] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Sixty-five percent of the adult population in the United States is overweight and 30% of the population is obese. There is mounting evidence that obesity is a risk factor for gynecologic cancers and may also adversely impact survival. The objectives of this review were to systematically evaluate and discuss the impact of overweight and obesity on endometrial, ovarian, and cervical cancer incidence and to review the data on the impact of obesity on treatment of these same gynecologic cancers. A PUBMED literature search was performed to identify articles in the English language that focused on the impact of obesity on cancer incidence and treatment. References of identified articles were also used to find additional related articles. Obesity profoundly increases the incidence of endometrial cancer, predominantly through the effects of unopposed estrogen. Although the data are less compelling in ovarian and cervical cancer, obesity may modestly increase the incidence of premenopausal ovarian cancer and might potentially increase cervical cancer incidence, perhaps as a result of the impact on glandular cancers or decreased screening compliance. Obese women with cancer have decreased survival; this may be disease-specific, the result of comorbid illnesses, or response to treatment. Obese women have increased surgical complications, may also have increased radiation complications, and there is no current consensus regarding appropriate chemotherapy dosing in the obese patient. Obesity is a serious health problem with significant effects on the incidence and treatment of the gynecologic malignancies. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to summarize the clear evidence that obesity is a risk factor for many cancers, including gynecologic malignancies; describe the role of unopposed estrogen in gynecologic cancers; and explain that obese women overall have a poorer survival rate when afflicted with cancer.
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Affiliation(s)
- Susan C Modesitt
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, University of Kentucky Chandler Medical Center, Lucille Markey Cancer Center, 800 Rose Street, Lexington, KY 40536-0298, USA.
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Yamashita H, Nakagawa K, Tago M, Shiraishi K, Nakamura N, Ohtomo K. Treatment results and prognostic analysis of radical radiotherapy for locally advanced cancer of the uterine cervix. Br J Radiol 2005; 78:821-6. [PMID: 16110104 DOI: 10.1259/bjr/13147816] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This study investigated treatment results and prognostic factors in radical radiotherapy for stage IIB-IVA cervical cancer. This is a retrospective analysis of 71 patients with cancer of the uterine cervix treated radically with external beam radiotherapy and high-dose-rate intracavitary brachytherapy between June 1991 and May 2004. In 47/71 (66%) of patients' chemotherapy was combined with radiotherapy. All 71 patients were retrospectively analysed. The median follow-up time was 34.8 months. The median age was 57 years (range 26-78 years) There were 21 patients (30%) in stage IIB, 3 (4%) stage IIIA, 40 (56%) stage IIIB, and 7 (10%) stage IVA. The 5-year overall survival rate was 83.5%, 77.0%, and 42.9% for stage IIB, III, and IVA, respectively. Federation Internationale de Gynocologie et d'Obstetrique (FIGO) classification stage and pelvic and para-aortic nodal status significantly affected survival in univariate analysis, but no treatment-related factor was found to be significant in multivariate analysis. In this study para-aortic nodal status was the most important prognostic factor in the radical radiotherapy of cervical cancer.
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Affiliation(s)
- H Yamashita
- Department of Radiology, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Kapp KS, Poschauko J, Tauss J, Berghold A, Oechs A, Lahousen M, Petru E, Winter R, Kapp DS. Analysis of the prognostic impact of tumor embolization before definitive radiotherapy for cervical carcinoma. Int J Radiat Oncol Biol Phys 2005; 62:1399-404. [PMID: 16029799 DOI: 10.1016/j.ijrobp.2004.12.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2004] [Revised: 12/24/2004] [Accepted: 12/25/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess whether embolization compromises the radiocurability of primary cervical cancer. METHODS AND MATERIALS Two hundred fifty-four patients with primary cervical cancer (International Federation of Gynecology and Obstetrics [FIGO] stages IB: 47; II: 91; IIIB: 102; IV: 14) were treated with external beam irradiation and Ir-192 high-dose-rate brachytherapy over a period of 15 years. Of these, 24 patients (9.4%) (FIGO stages IB: 1; II: 8; IIIB: 12; IV: 3) had had bilateral embolization of the internal iliac arteries before referral. The median age of the entire cohort was 66 years (range, 34-85 years). Tumor size was >5 cm and paraortic nodes were enlarged (> or =1 cm) on pretreatment CAT scan in 39.4% and 9.1% of patients, respectively. All patients with hemoglobin levels (hb-l) < or =11 g/dL (28.3%) received packed red cell transfusions (PRCT) before and/or during radiotherapy in an attempt to maintain levels >11 g/dL throughout treatment. Cross-table tests were used to compare the distribution of FIGO stage, tumor size, lymph node status, and pretreatment and treatment hb-l of embolized and nonembolized patients. The impact of embolization, along with the above-listed tumor characteristics, on disease-specific survival (DSS), pelvic control (PC), and distant metastases-free survival (MFS) was determined by univariate and multivariate analyses. RESULTS Embolized patients presented at a statistically significant younger median age (55 vs. 67 years; p = 0.003), with larger tumors (66.7% vs. 36.5%; p = 0.007), and lower pretreatment hb-l (75% vs. 23.5%; p < 0.001) than nonembolized patients. There was no significant difference in stage distribution or lymph node status, and although embolized patients responded better to PRCT (50% vs. 29.6%), this difference was not statistically significant. Univariate analysis showed a trend toward decreased DSS (p = 0.09) and PC (p = 0.07) for embolized patients but no effect on MFS, whereas all other variables tested were significantly correlated with DSS, PC, and MFS (all p < 0.001). In the multivariate model, tumor embolization, FIGO stage, and pretreatment hb-l ceased to impact significantly on outcome. Tumor size remained the most powerful independent predictor for all endpoints tested, followed by treatment hb-l. Paraortic node status was significantly correlated with DSS and MFS. CONCLUSION Although a trend toward poorer DSS and PC was observed in embolized patients, no impact on radiocurability could be demonstrated in multivariate analysis after controlling for the major tumor characteristics and treatment hb-l.
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Affiliation(s)
- Karin S Kapp
- Department of Radiation Oncology, Karl-Franzens University Medical School Graz, Graz, Austria
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Hyun Kim T, Choi J, Park SY, Lee SH, Lee KC, Yang DS, Shin KH, Cho KH, Lim HS, Kim JY. Dosimetric parameters that predict late rectal complications after curative radiotherapy in patients with uterine cervical carcinoma. Cancer 2005; 104:1304-11. [PMID: 16078262 DOI: 10.1002/cncr.21292] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Late rectal complication (LRC) was a major late complication in patients with uterine cervical carcinoma who were treated with a combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary irradiation (HDR-ICR). For the current study, the authors retrospectively evaluated dosimetric parameters that were correlated with LRC > or = Grade 2 in patients with uterine cervical carcinoma who were treated with curative radiotherapy, and they analyzed the appropriate dose estimates to the rectum that were predictive for LRC > or = Grade 2. METHODS Between July 1994 and September 2002, 157 patients who were diagnosed with Stage IB-IIIB cervical carcinoma and were treated with definitive radiotherapy were included. EBRT (41.4-66 grays [Gy] in 23-33 fractions) to the whole pelvis was delivered to all patients, with midline shielding performed after a 36-50.4 Gy external dose. HDR-ICR (21-39 Gy in 6-13 fractions to Point A) was administered at a rate of 2 fractions weekly after midline shielding of EBRT. LRC was scored using Radiation Therapy Oncology Group criteria. The total biologically effective dose (BED) at specific points, such as Point A (BED(Point A)), rectal point (BED(RP)), and maximal rectal point (BED(MP)), was determined by a summation of the EBRT and HDR-ICR components, in which the alpha/beta ratio was set to 3. Analyzed parameters included patient age, tumor size, stage, concurrent chemotherapy, ICR fraction size, RP ratio (dose at the rectal point according to the Point A dose), MP ratio (dose at the maximal rectal point according to the Point A dose), EBRT dose, BED(Point A), BED(RP), and BED(MP). RESULTS The 5-year actuarial overall rate of LRC > or = Grade 2 in all patients was 18.4%. Univariate analysis showed that the RP ratio, MP ratio, EBRT dose, BED(Point A), BED(RP), and BED(MP) were correlated with LRC > or = Grade 2 (P < 0.05). Multivariate analysis showed that, of all clinical and dosimetric parameters evaluated, only BED(RP) was correlated with LRC > or = Grade 2 (P = 0.009). The 5-year actuarial rate of LRC > or = Grade 2 was 5.4% in patients with a BED(RP) < 125 Gy(3) and 36.1% in patients with a BED(RP) > or = 125 Gy(3) (P < 0.001). CONCLUSIONS BED(RP) was a useful dosimetric parameter for predicting the risk of LRC > or = Grade 2 and should be limited to < 125 Gy(3) whenever possible to minimize the risk of LRC > or = Grade 2 in patients with uterine cervical carcinoma who are treated with a combination of EBRT and HDR-ICR. Cancer 2005.
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Affiliation(s)
- Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Korea
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Malaker K, Shukla V, D'Souza H, Weatherburn H. Minimizing urinary bladder radiation dose during brachytherapy for carcinoma of the cervix using balloon inflation technique. Int J Radiat Oncol Biol Phys 2005; 61:257-66. [PMID: 15629619 DOI: 10.1016/j.ijrobp.2004.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2003] [Revised: 03/19/2004] [Accepted: 05/03/2004] [Indexed: 11/18/2022]
Abstract
PURPOSE Radiotherapy is effective in treating cancer of the cervix. However, its success is associated with significant morbidity of the urinary bladder. This study has been designed to reduce the radiotherapy dose from the brachytherapy component of cervical cancer treatment to the urinary bladder to minimize radiation-induced morbidity. MATERIALS AND METHODS By inflating the balloon of a Foley catheter at the anterior fornix region, attempts were made to displace the urinary bladder in patients undergoing gynecological intracavitary brachytherapy. The radiation dose to the urinary bladder was then studied in 12 insertions without and 31 insertions with balloon inflation. RESULTS The increase in the distance from the intrauterine tandem source to a reference point in the base of the bladder and the resultant decrease in the radiation dose have been determined. A highly significant reduction in the radiation dose with an increase in distance between the source applicator and bladder base were achieved (p < 0.01 in both cases). CONCLUSION A significant reduction in radiation dose to the bladder base can be achieved by the technique described in this study. A three-dimensional plan generated using CT images can demonstrate the drawback of ICRU-38 bladder reference point. The technique is simple consistent and reproducible within an acceptable range.
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Affiliation(s)
- Kamal Malaker
- Radiation Oncology Section, Princess Norah Oncology Centre, Jeddah, Saudi Arabia.
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Chen SW, Liang JA, Yeh LS, Yang SN, Shiau AC, Lin FJ. Comparative study of reference points by dosimetric analyses for late complications after uniform external radiotherapy and high-dose-rate brachytherapy for cervical cancer. Int J Radiat Oncol Biol Phys 2004; 60:663-71. [PMID: 15380604 DOI: 10.1016/j.ijrobp.2004.05.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2003] [Revised: 05/03/2004] [Accepted: 05/10/2004] [Indexed: 11/19/2022]
Abstract
PURPOSE This study aimed to correlate and compare the predictive values of rectal and bladder reference doses of uniform external beam radiotherapy without shielding and high-dose-rate intracavitary brachytherapy (HDRICB) with late sequelae in patients with uterine cervical cancer. METHODS AND MATERIALS Between September 1992 and December 1998, 154 patients who survived more than 12 months after treatment were studied. Initially, they were treated with 10-MV X-rays (44 to 45 Gy/22 to 25 fractions over 4 to 5 weeks) to the whole pelvis, after which HDRICB was performed using (192)Ir remote afterloading at 1-week intervals for 4 weeks. The standard prescribed dose for each HDRICB was 6.0 Gy to point A. Patient- and treatment-related-factors were evaluated for late rectal complications using logistic regression modeling. RESULTS The probability of rectal complications showed better correlation of dose-response with increasing total ICRU (International Committee on Radiotherapy Units and Measurements) rectal dose. Multivariate logistic regression demonstrated a high risk of late rectal sequelae in patients who developed rectal complications (p = 0.0001;relative risk, 15.06;95% CI, 2.89 approximately 43.7) and total ICRU rectal dose greater than 16 Gy (p = 0.02;relative risk, 2.07;95% CI, 1.13 approximately 4.55). The high risk factors for bladder complications were seen in patients who developed rectal complications (p = 0.0001;relative risk, 15.2;95% CI, 2.81 approximately 44.9) and total ICRU bladder dose greater than 24 Gy (p = 0.02;relative risk, 8.93;95% CI, 1.79 approximately 33.1). CONCLUSION This study demonstrated the predictive value of ICRU rectal and bladder reference dosing in HDRICB for patients receiving uniform external beam radiation therapy without central shielding. Patients who had a total ICRU rectal dose greater than 16 Gy, or a total ICRU bladder dose over 24 Gy, were at risk of late sequelae.
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Affiliation(s)
- Shang-Wen Chen
- Department of Radiation Therapy and Oncology, School of Medicine, China Medical University Taichung, Taiwan.
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Nam TK, Ahn SJ. A prospective randomized study on two dose fractionation regimens of high-dose-rate brachytherapy for carcinoma of the uterine cervix: comparison of efficacies and toxicities between two regimens. J Korean Med Sci 2004; 19:87-94. [PMID: 14966348 PMCID: PMC2822271 DOI: 10.3346/jkms.2004.19.1.87] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To evaluate the toxicities and efficacies of two fractionation regimens of high-dose-rate brachytherapy in uterine cervical cancer, patients were stratified by stage Ib-IIa versus IIb-IVa, and randomly assigned to receive 3 Gy fractions (group A) or 5 Gy fractions (group B). External radiotherapy was performed using a 10 MV radiography with a daily 1.8 Gy up to 30.6 Gy to the whole pelvis, and then with a midline shield up to 45.0 Gy. Brachytherapy was performed with 3 Gy x 10 times or 5 Gy x 5 times, and this was followed by booster brachytherapy of a smaller fraction to the residual tumor. Between August 1999 to July 2000, 46 patients were eligible. Median follow-up period was 42 months (5-49). The range of age was 37-83 yr (median, 58). The three-year disease-specific survival rates of group A (n=23) and B (n=23) were 90.5%, 84.9%, respectively (p=0.64). The three-year pelvic control rates of group A and B were 90.0% and 90.9%, respectively (p=0.92). The incidences of late complications of the rectum or bladder of grade 2 or greater in groups A and B were 23.8% and 9.1%, respectively (p=0.24). Our study showed that the results of two regimens were comparable. Fractionation regimen using 5 Gy fractions seems to be safe and effective, and offers shorter treatment duration.
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Affiliation(s)
- Taek Keun Nam
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Sung Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
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Jones ND, Rankin J, Gaffney DK. Is simulation necessary for each high-dose-rate tandem and ovoid insertion in carcinoma of the cervix? Brachytherapy 2004; 3:120-4. [PMID: 15533802 DOI: 10.1016/j.brachy.2004.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Revised: 07/01/2004] [Accepted: 07/01/2004] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the dose variation in high-dose-rate (HDR) intracavitary brachytherapy for cancer of the cervix when treatment planning is performed prior to each applicator insertion versus when the initial plan is used for each treatment. METHODS AND MATERIALS Fourteen patients with carcinoma of the cervix were treated with chemoradiotherapy followed by five intracavitary tandem and ovoid insertions of 600 cGy/fraction. We modified the actual plans to calculate the dose each dose point would have received using only the treatment plan created for the initial fraction. RESULTS An increase in the percent dose to the rectum, bladder, and vaginal surface of 5%, cGy (p = 0.038), 6% (p = 0.006), and 11%, respectively, were observed when the initial treatment plan was used versus using the optimized treatment plan for each insertion. The greatest single change resulted in a percent increase of 35%, 30%, and 45% to the rectum, bladder, and vaginal surface points, respectively. CONCLUSIONS Increased dose to at-risk structures occurred when individualized treatment planning was not performed. Since a significant increase in dose to the rectum (p = 0.038) and bladder (p = 0.006) was obtained without customized treatment planning, we continue to advocate individualized treatment planning in HDR tandem and ovoid insertions for the treatment of cervix cancer.
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Affiliation(s)
- Nathan D Jones
- Department of Radiation Oncology and Huntsman Cancer Institute, University of Utah Medical Center, 1950 Circle of Hope, Salt Lake City, UT 84112, USA
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Pras E, Wouda J, Willemse PHB, Midden ME, Zwart M, de Vries EGE, Schultz WCMW. Pilot study of vaginal plethysmography in women treated with radiotherapy for gynecological cancer. Gynecol Oncol 2003; 91:540-6. [PMID: 14675673 DOI: 10.1016/j.ygyno.2003.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE After pelvic radiotherapy for gynecological cancer, changes in the vaginal epithelium might influence sexual arousal and satisfaction, leading to dyspareunia and relational problems. The aim of the study was to determine the feasibility of vaginal plethysmography in order to measure physical late effects of this therapy on sexual function. METHODS Patients treated with radiotherapy for cervical, endometrial, or ovarian cancer, who were in complete remission for over 1 year, underwent vaginal plethysmography to measure changes in vaginal vasocongestion, while watching erotic video fragments. Afterward two questionnaires, designed to measure feelings of sexual arousal during the video, and to identify sexual dysfunction, were completed. The results were compared with those of healthy women. RESULTS Patients (n = 9) and volunteers (n = 8) did not differ in baseline amplitude of plethysmography and showed comparable changes in vaginal vasocongestion during the various video fragments. The decline in amplitude during the last video fragment in the patient group did not reach significance, but the group of patients is small and heterogeneous. Addressing subjective sexual arousal during the video, patients reported less feelings of lust and desire and fewer bodily sensations while watching than the controls. Patients worried more about the sexual satisfaction of their partners than controls. CONCLUSION Vaginal plethysmography can be used to measure vaginal vasocongestion in patients treated with radiotherapy to the proximal vagina. In this pilot study the changes of vaginal vasocongestion during sexual arousal between patients and healthy volunteers were not different. This correlates with a comparable sexual satisfaction, although patients reported less feelings of lust.
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Affiliation(s)
- Elisabeth Pras
- Department of Radiation Oncology, University Hospital, Groningen, The Netherlands.
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Maduro JH, Pras E, Willemse PHB, de Vries EGE. Acute and long-term toxicity following radiotherapy alone or in combination with chemotherapy for locally advanced cervical cancer. Cancer Treat Rev 2003; 29:471-88. [PMID: 14585258 DOI: 10.1016/s0305-7372(03)00117-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Randomised studies in locally advanced cervical cancer patients showed that cisplatin should be given concurrently with radiotherapy, because of a better long-term survival compared to radiotherapy alone. This increases the relevance of treatment related toxicity. This review summarises the acute and long-term toxicity of radiotherapy given with or without chemotherapy for cervical cancer. Acute toxicity (all grades) of radiotherapy is reported in 61% of the patients in the rectosigmoid, in 27% as urological, in 27% as skin and in 20% as gynaecological toxicity. Moderate and severe morbidity consists of 5% to 7% gastrointestinal and 1% to 4% genitourinary toxicity. Adding chemotherapy to radiotherapy increases acute haematological toxicity to 5% to 37% of the patients and nausea and vomiting in 12% to 14%. Late effects of radiotherapy include gastrointestinal, urological, female reproductive tract, skeletal and vascular toxicity, secondary malignancies and quality of life issues. For at least 20 years after treatment, new side effects may develop. Gastrointestinal toxicity usually occurs in the first 2 years after treatment in about 10% of the patients. The incidence of moderate and severe urological toxicity can increase up to 10% and rises over time. Gynaecological toxicity usually occurs shortly after treatment while skeletal and vascular toxicity can occur years to decades later. Thus far, no increase in late toxicity has been observed after the addition of cisplatin to radiotherapy. Finally, methods to prevent or decrease late toxicity and therapeutical options are discussed. However, most randomised studies still have a limited follow-up period.
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Affiliation(s)
- J H Maduro
- Department of Radiotherapy, University Hospital Groningen, Groningen, The Netherlands
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Toita T, Kakinohana Y, Ogawa K, Adachi G, Moromizato H, Nagai Y, Maehama T, Sakumoto K, Kanazawa K, Murayama S. Combination external beam radiotherapy and high-dose-rate intracavitary brachytherapy for uterine cervical cancer: analysis of dose and fractionation schedule. Int J Radiat Oncol Biol Phys 2003; 56:1344-53. [PMID: 12873679 DOI: 10.1016/s0360-3016(03)00288-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine an appropriate dose and fractionation schedule for a combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary brachytherapy (HDR-ICBT) for uterine cervical cancer. METHODS Eighty-eight patients with uterine cervical squamous cell carcinoma treated with EBRT and HDR-ICBT were analyzed. Twenty-five patients were classified as early disease (nonbulky Stage I/II, less than 4-cm diameter) and 63 patients as advanced disease (greater than 4 cm diameter or Stage IIIB) according to the American Brachytherapy Society definition. Tumor diameter was measured by MRI. Pelvic EBRT was delivered before applications of ICBT. HDR-ICBT was performed once a week, with a fraction point A dose of 6 Gy. Source loadings corresponded to the Manchester System for uterine cervical cancer. No planned optimization was done. A Henschke-type applicator was mostly used (86%). Median cumulative biologic effective dose (BED) at point A (EBRT + ICBT) was 64.8 Gy(10) (range: 48-76.8 Gy(10)) for early disease, and 76.8 Gy(10) (range: 38.4-86.4 Gy(10)) for advanced disease. Median cumulative BED at ICRU 38 reference points (EBRT + ICBT) was 97.7 Gy(3) (range: 59.1-134.4 Gy(3)) at the rectum, 97.8 Gy(3) (range: 54.6-130.4 Gy(3)) at the bladder, and 324 Gy(3) (range: 185.5-618 Gy(3)) at the vagina. Actuarial pelvic control rate and late complication rate were analyzed according to cumulative dose and calculated BED. RESULTS The 3-year actuarial pelvic control rate was 82% for all 88 patients: 96% for those with early disease, and 76% for advanced disease. For pelvic control, no significant dose-response relationship was observed by treatment schedules and cumulative BED at point A for both early and advanced disease. The 3-year actuarial late complication rates (Grade > or =1) were 12% for proctitis, 11% for cystitis, and 14% for enterocolitis. There were significant differences on the incidence of proctitis (p < 0.0001) and enterocolitis (p < 0.0001), but not for cystitis by the treatment schedules and cumulative point A BED. All 4 patients treated with 86.4 Gy(10) at point A suffered both proctitis and enterocolitis. Patients with cumulative BED at rectal point of > or =100 Gy(3) had significantly higher incidence of proctitis (31% vs. 4%, p = 0.013). CONCLUSIONS In view of the therapeutic ratio, cumulative BED 70-80 Gy(10) at point A is appropriate for uterine cervical cancer patients treated with a combination of EBRT and HDR-ICBT. Present results and data from other literatures suggested that cumulative BED at the rectal point should be kept below 100-120 Gy(3) to prevent late rectal complication.
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Affiliation(s)
- Takafumi Toita
- Department of Radiology, University of the Ryukyus School of Medicine, Okinawa, Japan.
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Okkan S, Atkovar G, Sahinler I, Oner Dinçbaş F, Koca A, Köksal S, Turkan S, Uzel R. Results and complications of high dose rate and low dose rate brachytherapy in carcinoma of the cervix: Cerrahpaşa experience. Radiother Oncol 2003; 67:97-105. [PMID: 12758245 DOI: 10.1016/s0167-8140(03)00030-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the results and complications of treatment with high dose rate (HDR) compared to low dose rate (LDR) brachytherapy in cervical carcinoma. METHODS Three hundred and seventy patients who were treated with external irradiation and intracavitary brachytherapy and followed for more than 2 years between 1978 and 1998 have been recently updated. The low dose rate group consisted of 77 cases treated between 1978 and 1982 and HDR group consisted of 293 cases treated between 1982 and 1998. All patients first received external irradiation with 60Co or 9-18 MV photons and a median dose of 54 Gy was given in 6 weeks. In the LDR group, intracavitary treatment was given with Manchester applicators loaded with radium (30 mg) in an intrauterine tube and 20 mg in vaginal ovoids. The dose delivered to point A was on average 32 Gy in one application. In the HDR group, a total dose of 24 Gy was given to point A in three insertions 1 week apart. The dose rate was 0.62 Gy at point A. RESULTS The 5-year pelvic control rate was found to be 73% in the HDR group, compared with 86% in the radium group for stage I cases. In stage IIB and IIIB cases, the rates were 68% and 45% for HDR and 65% and 53% for LDR, respectively. In all stages, there was no statistical difference in pelvic control and survival rates between the two groups. Overall incidence of late complications was found as 31.1% and 31.9% in HDR and LDR groups, respectively. The grade 2-4 late complication rate was 14% in the HDR group compared to 19% in the LDR group (P>0.05). CONCLUSION HDR brachytherapy in the management of the cervix appears to be a safe and efficacious approach. Pelvic control, survival and complications rates are quite similar when compared with LDR.
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Affiliation(s)
- Sait Okkan
- Department of Radiation Oncology, Cerrahpaşa Medical School, Istanbul University, 34303, Istanbul, Turkey
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Wong FCS, Tung SY, Leung TW, Sze WK, Wong VYW, Lui CMM, Yuen KK, O SK. Treatment results of high-dose-rate remote afterloading brachytherapy for cervical cancer and retrospective comparison of two regimens. Int J Radiat Oncol Biol Phys 2003; 55:1254-64. [PMID: 12654435 DOI: 10.1016/s0360-3016(02)04525-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To review the treatment results and complications of high-dose-rate (HDR) intracavitary brachytherapy for patients with carcinoma of the cervix in a single institute and to compare them with those of low-dose-rate (LDR) brachytherapy reported in the literature. METHODS AND MATERIALS Two hundred twenty patients with carcinoma of the cervix were treated by primary radiotherapy between 1991 and 1998. The median age was 63 (range 24-84). The distribution according to Federation of Gynecology and Obstetrics (FIGO) staging system was as follows: Stage IB, 11.4%; IIA, 9.1%; IIB, 50.9%; IIIA, 3.6%; IIIB, 23.2%; and IVA, 1.8%. They were treated with whole pelvic irradiation giving 40 Gy to the midplane in 20 fractions over 4 weeks. This was followed by parametrial irradiation, giving 16-20 Gy in 8-10 fractions. HDR intracavitary brachytherapy was given weekly, with a dose of 7 Gy to point A for three fractions and, starting from 1996, 6 Gy weekly for four fractions. The median overall treatment time was 50 days (range 42-73 days). The median follow-up time was 4.7 years (range 3 months to 11.1 years). Multivariate analysis was performed using the Cox regression proportional hazards model. RESULTS The complete remission rate after radiotherapy was 93.4% (211/226). The 5-year actuarial failure-free survival (FFS) and cancer-specific survival (CSS) rates for stage IB, IIA, IIB, IIIA, IIIB, and IVA were 87.7% and 86.6%, 85% and 85%, 67.8% and 74%, 46.9% and 54.7%, 44.8% and 50.4%, 0% and 25%, respectively. On multivariate analysis, young age (< 50) (p = 0.0054), adenocarcinoma (p = 0.0384), and stage (p = 0.0005) were found to be independent poor prognostic factors. The 5-year actuarial major complication rates (Grade 3 or above) were as follows: proctitis, 1.0%; cystitis, 0.5%; enteritis, 1.3%; and overall, 2.8%. On multivariate analysis, history of pelvic surgery was a significant prognosticator. The two HDR fractionation schedules were not a significant prognosticator in predicting disease control and complications. CONCLUSION Our experience in treating cervical cancer with HDR intracavitary brachytherapy is encouraging. Our treatment results and complication rates were compatible with those of the LDR series. Further studies are eagerly awaited to better define the optimal fractionation schedule for HDR brachytherapy and the schedule on how chemotherapy may be combined with it.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/radiotherapy
- Adenocarcinoma/surgery
- Adult
- Aged
- Aged, 80 and over
- Brachytherapy/adverse effects
- Brachytherapy/methods
- Carcinoma, Adenosquamous/mortality
- Carcinoma, Adenosquamous/pathology
- Carcinoma, Adenosquamous/radiotherapy
- Carcinoma, Adenosquamous/surgery
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Squamous Cell/surgery
- Combined Modality Therapy
- Cystitis/etiology
- Disease-Free Survival
- Dose Fractionation, Radiation
- Enteritis/etiology
- Female
- Follow-Up Studies
- Humans
- Life Tables
- Lymphatic Irradiation
- Lymphatic Metastasis
- Middle Aged
- Neoplasm Staging
- Particle Accelerators
- Pelvis
- Proctitis/etiology
- Proportional Hazards Models
- Radiation Injuries/etiology
- Radiotherapy, High-Energy/adverse effects
- Remission Induction
- Retrospective Studies
- Survival Analysis
- Treatment Outcome
- Uterine Cervical Neoplasms/radiotherapy
- Uterine Cervical Neoplasms/surgery
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Affiliation(s)
- Frank C S Wong
- Department of Clinical Oncology, Tuen Mun Hospital, (Special Administrative Region), Hong Kong, People's Republic of China.
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Hareyama M, Sakata KI, Oouchi A, Nagakura H, Shido M, Someya M, Koito K. High-dose-rate versus low-dose-rate intracavitary therapy for carcinoma of the uterine cervix: a randomized trial. Cancer 2002; 94:117-24. [PMID: 11815967 DOI: 10.1002/cncr.10207] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This was a prospective randomized clinical trial undertaken at our institution to compare low-dose-rate (LDR) intracavitary radiation therapy versus high-dose-rate (HDR) intracavitary radiation therapy for the treatment of cervical carcinoma. METHODS From January 1984 to December 1997, a total of 132 patients with Stage II or IIIB of invasive carcinoma of the uterine cervix were entered into this randomized study. Treatment arm by HDR or LDR was allocated according to the month of each patient's birth. External irradiation consisted of whole pelvis irradiation and pelvic irradiation. Doses of external irradiation for both groups were identical. The authors used 0.588 as the conversion factor of total intracavitary dose from LDR to HDR. RESULTS The 5-year disease specific survival rates of Stage II and III patients treated with HDR were 69% and 51% whereas those with LDR were 87% and 60%, respectively. The 5-year pelvic recurrence free survival rates of Stage II and III patients treated with HDR were 89% and 73% whereas those with LDR were 100% and 70%, respectively. There was no significant difference in disease specific survival or pelvic recurrence free survival rates between HDR and LDR. The actuarial complication rate (Radiation Therapy Oncology Group Grade 3, 4, or 5) at 5 years was 10% in the HDR group and 13% in the LDR group, and the difference between the HDR and LDR groups was not statistically significant. CONCLUSIONS The pelvic control or actuarial complication rates were comparable between HDR and LDR treatment. The difference between the disease specific survival rates for HDR and LDR was not statistically significant for Stage II or III, although in Stage II, patients treated with LDR appeared to have a better survival rate than those treated with HDR.
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Affiliation(s)
- Masato Hareyama
- Department of Radiology, Sapporo Medical University, School of Medicine, Sapporo, Japan.
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Mai J, Rownd J, Erickson B. CT-guided high–dose-rate dose prescription for cervical carcinoma. Brachytherapy 2002; 1:27-35. [PMID: 15062184 DOI: 10.1016/s1538-4721(02)00009-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2001] [Revised: 12/18/2001] [Accepted: 02/22/2002] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the use of CT imaging to guide dose prescription for high-dose-rate brachytherapy in cervical cancer, by defining the uterine wall thickness and the proximity of the rectosigmoid, bladder, and small bowel. METHODS AND MATERIALS From 1994-2000, 40 patients with cervical cancer underwent treatment with external beam radiation therapy plus high-dose-rate brachytherapy. A pelvic CT scan was performed following applicator placement, and was analyzed to determine anterior and posterior uterine wall thickness, and the distance to the bladder and rectosigmoid. The dose prescription was initially at Point A, but in some patients, was altered based on the thickness of the uterine wall. RESULTS Measurements in the region of the lower and upper uterine wall were analyzed separately. Nearly half (46%) of the patients had an average anterior or posterior wall thickness of <20 mm. A correlation was observed between thinner anterior lower uterine walls and increased late bladder and ureteral toxicity, and between thinner anterior upper uterine walls and increased late small-bowel toxicity. CONCLUSIONS A significant number of patients have uterine walls <2 cm in thickness. The use of CT imaging can identify patients in whom the conventional dose specification point may need to be altered to maintain the therapeutic ratio.
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Affiliation(s)
- Julie Mai
- Department of Radiation Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Song DY, Lawrie WT, Abrams RA, Kafonek DR, Bayless TM, Welsh JS, DeWeese TL. Acute and late radiotherapy toxicity in patients with inflammatory bowel disease. Int J Radiat Oncol Biol Phys 2001; 51:455-9. [PMID: 11567821 DOI: 10.1016/s0360-3016(01)01629-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the incidence of gastrointestinal complications in patients with inflammatory bowel disease (IBD) receiving radiotherapy (RT) and to identify possibly avoidable factors associated with these complications. METHODS AND MATERIALS Twenty-four patients were identified and their records reviewed; all had a history of IBD before receiving RT to fields encompassing some portion of the gastrointestinal tract (Crohn's disease) or to the abdomen or pelvis (ulcerative colitis or IBD not otherwise specified). RESULTS Five of 24 patients (21%) experienced Grade > or =3 acute gastrointestinal toxicity; all 5 received concurrent chemotherapy. Two of 24 patients (8%) experienced Grade > or =3 late gastrointestinal toxicity. There were no significant correlations between complications and IBD type, prior IBD-related surgery, use of medications for IBD, or status of IBD. CONCLUSION Patients with IBD may have an increased risk for severe acute RT-related gastrointestinal complications that is more modest than generally perceived, because all patients who had Grade > or =3 acute complications in this study had received concurrent chemotherapy (p = 0.04). Further study is needed to assess this risk, as well as the impact of RT on these patients' future gastrointestinal morbidity.
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Affiliation(s)
- D Y Song
- Division of Radiation Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
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50
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Ferrigno R, dos Santos Novaes PE, Pellizzon AC, Maia MA, Fogarolli RC, Gentil AC, Salvajoli JV. High-dose-rate brachytherapy in the treatment of uterine cervix cancer. Analysis of dose effectiveness and late complications. Int J Radiat Oncol Biol Phys 2001; 50:1123-35. [PMID: 11483321 DOI: 10.1016/s0360-3016(01)01533-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE This retrospective analysis aims to report results of patients with cervix cancer treated by external beam radiotherapy (EBR) and high-dose-rate (HDR) brachytherapy. METHODS AND MATERIALS From September 1992 to December 1996, 138 patients with FIGO Stages II and III and mean age of 56 years were treated. Median EBR to the whole pelvis was 45 Gy in 25 fractions. Parametrial boost was performed in 93% of patients, with a median dose of 14.4 Gy. Brachytherapy with HDR was performed during EBR or following its completion with a dose of 24 Gy in four weekly fractions of 6 Gy to point A. Median overall treatment time was of 60 days. Patient age, tumor stage, and overall treatment time were variables analyzed for survival and local control. Cumulative biologic effective dose (BED) at rectal and bladder reference points were correlated with late complications in these organs and dose of EBR at parametrium was correlated with small bowel complications. RESULTS Median follow-up time was 38 months. Overall survival, disease-free survival, and local control at 5 years was 53.7%, 52.7%, and 62%, respectively. By multivariate and univariate analysis, overall treatment time up to 50 days was the only statistically significant adverse variable for overall survival (p = 0.003) and actuarial local control (p = 0.008). The 5-year actuarial incidence of rectal, bladder, and small bowel late complications was 16%, 11%, and 14%, respectively. Patients treated with cumulative BED at rectum points above 110 Gy(3) and at bladder point above 125 Gy(3) had a higher but not statistically significant 5-year actuarial rate of complications at these organs (18% vs. 12%, p = 0.49 and 17% vs. 9%, p = 0.20, respectively). Patients who received parametrial doses larger than 59 Gy had a higher 5-year actuarial rate of complications in the small bowel; however, this was not statistically significant (19% vs. 10%, p = 0.260). CONCLUSION This series suggests that 45 Gy to the whole pelvis combined with four fractions of 6 Gy to point A with HDR brachytherapy is an effective and safe fractionation schedule in the treatment of Stages II and III cervix cancer if realized up to 50 days. To decrease the small bowel complications, we decreased the superior border of the parametrial fields to the S2-S3 level and the total dose to 54 Gy.
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Affiliation(s)
- R Ferrigno
- Department of Radiation Oncology, Hospital do Câncer A.C. Camargo, São Paulo, Brazil.
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