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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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Pelizzola M, Tanderup K, Chopra S, Jürgenliemk-Schulz IM, Nout R, Kirchheiner K, Spampinato S. Co-occurrence of symptoms after radiochemotherapy in locally advanced cervix cancer patients: a cluster analysis. Acta Oncol 2023; 62:1479-1487. [PMID: 37906286 DOI: 10.1080/0284186x.2023.2271252] [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: 06/26/2023] [Accepted: 10/06/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND State of the art combined radiochemotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) has shown improved disease control and survival as well as a significant reduction of organ related morbidity. However, LACC cancer survivors are still experiencing a spectrum of symptoms. The aim of this study was to identify co-occurring symptoms in cervix cancer survivors by using patient-reported outcome and physician assessed morbidity. MATERIALS AND METHOD EMBRACE I is a multicenter prospective observational study with 1416 LACC patients (2008-2015). Information on physician-assessed morbidity and patient-reported outcome was assessed at baseline and at regular follow-ups up with the CTCAE v.3 and EORTC-C30/CX24, respectively. Patients with at least 2 years of follow-up were included and data from 3 months to 2 years was used in the analysis. Factor analysis was used on both EORTC and CTCAE data with symptoms and follow-ups as observations. The extracted factors represent clusters of symptoms. Subsequently, regression models were built to investigate associations between the symptom clusters and QOL. RESULTS The analysis included 742 patients. Despite the differences in the definition of physician-assessed and patient-reported symptoms, similar clusters are identified by the two assessment methods. Three main organ-related clusters are recognized for urinary, gastro-intestinal and vaginal morbidity. Furthermore, a general symptoms cluster where fatigue, pain, insomnia, neuropathy, and hot flashes have large weights is found. Lastly, a cluster with nausea, vomit and lack of appetite is also identified. The general, gastrointestinal and nausea clusters show significant associations with general QOL. CONCLUSIONS This analysis on both PRO and physician-assessed morbidity found a cluster associated with general symptoms and organ-related symptom clusters (urinary, gastrointestinal, vaginal). This shows that LACC survivors experience a variety of co-occurring symptoms. Our analysis also shows that the cluster of general symptoms is associated with a decrease in QOL.
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Affiliation(s)
- Marta Pelizzola
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Ina M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, CX, The Netherlands
| | - Remi Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sofia Spampinato
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Kibret YM, Tigeneh W, Jemal A, Kantelhardt EJ. Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report. JCO Glob Oncol 2023; 9:e2200407. [PMID: 37595167 PMCID: PMC10581656 DOI: 10.1200/go.22.00407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 08/20/2023] Open
Abstract
PURPOSE Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia. MATERIALS AND METHODS A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period. RESULTS During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib-IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients. CONCLUSION The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.
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Affiliation(s)
- Yitbarek M. Kibret
- Oncology Department, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
- Global Health Working Group, Martin-Luther-University Halle-Wittenberg, Germany
| | | | - Ahmedin Jemal
- Surveillance and Health Service Research, American Cancer Society, Atlanta, GA
| | - Eva J. Kantelhardt
- Global Health Working Group, Martin-Luther-University Halle-Wittenberg, Germany
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Jaswal G, Benipal R, Bhatty SG, Garg P, Kang MS. Comparison of Two High Dose Rate Brachytherapy Regimes. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2023; 15:S1062-S1064. [PMID: 37694100 PMCID: PMC10485489 DOI: 10.4103/jpbs.jpbs_221_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 09/12/2023] Open
Abstract
Background Two HDR brachytherapy regimes were compared, 9.5 Gray per fraction for two fractions and 7.5 Gray per fraction for three fractions. Materials and Methods A total of 80 patients with histologically evident squamous cell carcinoma cervix were taken in the current research after randomization. Radiotherapy dose delivered was 50 Gray/25#/5 weeks with concomitant chemotherapy with weekly cisplatin 35 mg/m2. Following external chemoradiation, patients were randomized into two arms. In Arm A, 40 patients were given high dose rate (HDR) brachytherapy of weekly 7.5 Gray in three fractions over 3 weeks. In Arm B, 40 patients were given high dose rate (HDR) brachytherapy of weekly 9.5 Gray in two fractions over 2 weeks. BED and LQED had been calculated, and the evaluation of response and consequences was examined. Results In Arm A, BED to point A was 99.38 ± 0.00 and EQD2 to point A was 82.81 ± 0.00. In Arm B, BED to point A was 97.05 ± 0.00 and EQD2 to point A was 80.89 ± 0.00. With respect to rectum in Arm A, BED rectum was 108.66 ± 11.43 and EQD2 rectum was 65.07 ± 6.84. In Arm B, BED rectum was 107 ± 10.83 and EQD2 rectum was 64.21 ± 6.49. Similarly in Arm A, BED bladder was 107.86 ± 10.23 and EQD2 bladder was 64.59 ± 6.13. In arm B, BED bladder was 104.14 ± 10.79 and EQD2 bladder was 62.36 ± 6.46. Conclusion In a follow-up of 6 months, no statistical significance in terms of local control as well as complications rates in both the arms. Our research demonstrates that two fractions of HDR are comparable with three fractions of HDR.
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Affiliation(s)
- Gaurav Jaswal
- Department of Radiation Oncology, Dr. Prem Super Speciality and Cancer Hospital, Panipat, Haryana, India
| | - Raja Benipal
- Department of Radiation Oncology, Government Medical College, Patiala, Punjab, India
| | - Seema G. Bhatty
- Department of Obstetrics and Gynaecology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Pardeep Garg
- Department of Radiation Oncology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Manraj S. Kang
- Assoc Professor, Department of Radiation Oncology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Dejanovic D, Specht L, Czyzewska D, Kiil Berthelsen A, Loft A. Response Evaluation Following Radiation Therapy With 18F-FDG PET/CT: Common Variants of Radiation-Induced Changes and Potential Pitfalls. Semin Nucl Med 2022; 52:681-706. [PMID: 35835618 DOI: 10.1053/j.semnuclmed.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/11/2022]
Abstract
Radiation therapy (RT) is one of the cornerstones in cancer treatment and approximately half of all patients will receive some form of RT during the course of their cancer management. Response evaluation after RT and follow-up imaging with 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) can be complicated by RT-induced acute, chronic or consequential effects. There is a general consensus that 18F-FDG PET/CT for response evaluation should be delayed for 12 weeks after completing RT to minimize the risk of false-positive findings. Radiation-induced late side effects in normal tissue can take years to develop and eventually cause symptoms that on imaging can potentially mimic recurrent disease. Imaging findings in radiation induced injuries depend on the normal tissue included in the irradiated volume and the radiation therapy regime including the total dose delivered, dose per fraction and treatment schedule. The intent for radiation therapy should be taken in consideration when evaluating the response on imaging, that is palliative vs curative or neoadjuvant vs adjuvant RT. Imaging findings can further be distorted by altered anatomy and sequelae following surgery within the radiation field. An awareness of common PET/CT-induced changes/injuries is essential when interpreting 18F-FDG PET/CT as well as obtaining a complete medical history, as patients are occasionally scanned for an unrelated cause to previously RT treated malignancy. In addition, secondary malignancies due to carcinogenic effects of radiation exposure in long-term cancer survivors should not be overlooked. 18F-FDG PET/CT can be very useful in response evaluation and follow-up in patients treated with RT, however, variants and pitfalls are common and it is important to remember that radiation-induced injury is often a diagnosis of exclusion.
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Affiliation(s)
- Danijela Dejanovic
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Dorota Czyzewska
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kiil Berthelsen
- Department of Oncology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Annika Loft
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Urban R, Wong J, Lim P, Zhang S, Spadinger I, Olson R, Bachand F, Ho C, Tinker AV, Gondara L, Hamilton SN. Cervical cancer patient reported gastrointestinal outcomes: intensity/volumetric modulated vs. 3D conformal radiation therapy. J Gynecol Oncol 2022; 33:e70. [PMID: 35882607 PMCID: PMC9428301 DOI: 10.3802/jgo.2022.33.e70] [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: 09/23/2021] [Revised: 06/12/2022] [Accepted: 06/21/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate gastrointestinal (GI) patient reported outcomes (PROs) in cervical cancer patients treated with definitive radiotherapy (RT), comparing 3D conformal RT (3DCRT) vs. intensity modulated/volumetric modulated arc therapy (IMRT/VMAT). METHODS An analysis of patients treated with definitive RT between 2015-2018 was performed. GI PROs were prospectively collected at baseline, during RT (acute), ≤12 weeks after RT (subacute), and >12 weeks after RT (late). GI PROs evaluated three symptom domains: bowel problems (BPs), bowel bother (BB), and abdominal problems (APs). Multiple linear regression analysis was performed to investigate associations between mean changes of symptom scores with clinical and dosimetric variables. RESULTS The cohort included 167 patients. A total of 100 (60%) patients were treated with IMRT/VMAT and 67 (40%) with 3DCRT. In the subacute phase, the mean change of symptom scores from baseline in 3DCRT vs. IMRT/VMAT were +0.9 vs. -1.15 (p=0.004) for BP, +2.18 vs. -0.10 (p=0.019) for BB, and +1.41 vs. -0.38 (p=0.021) for AP. Likewise, in the late phase, mean changes were +0.72 vs. -0.82 (p=0.014) for BP, +1.98 vs. -0.03 (p=0.008) for BB, and +1.29 vs. -0.31 (p<0.001) for AP. On multiple linear regression, use of 3DCRT vs. IMRT/VMAT was associated with greater mean changes in subacute BP (p=0.023) and late phase AP (p=0.019). A higher small bowel V50Gy was associated increased symptom scores in late AP (p=0.012). CONCLUSION 3DCRT was associated with significantly greater worsening of GI PRO symptom scores in the subacute and late phase. These data support the ongoing use of IMRT/VMAT in routine practice.
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Affiliation(s)
- Ryan Urban
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Justin Wong
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Peter Lim
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Susan Zhang
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Medical Physics, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Ingrid Spadinger
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Medical Physics, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Robert Olson
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Prince George, Prince George, BC, Canada
| | - Francois Bachand
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Kelowna, Kelowna, BC, Canada
| | - Clement Ho
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Surrey, Surrey, BC, Canada
| | - Anna V Tinker
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Medical Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Lovedeep Gondara
- Department of Population Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Sarah Nicole Hamilton
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada.
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Kavuma A, Luutu I, Kibudde S, Bangidde C. A retrospective review of conventional versus hypo-fractionated pelvic radiotherapy for locally advanced cervical cancer, in limited-resource countries: The Uganda experience. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.4102/sajo.v5i0.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Cervical cancer incidence in Uganda is 54.8 per 100 000 population. We annually treat over 800 new cervical cancers (40% of the workload), which is challenging to treat such numbers in limited resources settings. From July 2011, we commenced the use of hypo-fractionated radiotherapy (HFRT) of 45 Gy/15 fraction (#) as an alternative to conventional fractionated radiotherapy (CFRT) of 50 Gy/25#, for treatment of locally advanced cervical cancer (LACC).Aim: To compare the 5-year follow-up treatment outcomes between CFRT and HFRT.Settings: The study analysed patients treated at the Uganda Cancer Institute – a limited resource institution.Methods: This was a non-randomised, retrospective study, where 414 patients’ files were reviewed according to demographic, clinical, radiotherapy fractionations and outcomes. Inclusion criteria were International Federation of Gynecology and Obstetrics stages IIB–IIIB cervical cancer cases and had completed external beam radiotherapy and intracavitary radiotherapy.Results: Squamous cell carcinomas were 93.6% and adenocarcinomas were 3.0%. The median age was 49.5 (interquartile range [IQR]: 40.0–56.0) years. Stages IIB/IIIA/IIIB were 36.2%, 8.2%, 55.6%, respectively. Human immunodeficiency virus serology was positive, negative, and unknown in 70 (16.9%), 116 (28.0%) and 228 (55.1%), respectively. Concurrent chemo-radiation was administered in 182 (44.0%) patients. Conventional fractionated radiotherapy and HFRT were 221 (53.4%) and 193 (46.6%), respectively. At 6 months, the overall response rate was 73.3% for CFRT compared with 67.6% for HFRT (p = 0.085), whilst the grades 0–1 toxicities were 94.5% and for 94.7% CFRT and HFRT, respectively (p = 0.080). At 60 months, the survival probabilities were 44.9% for CFRT and 46.6% for HFRT (p = 0.293).Conclusion: There is no significant statistical difference between CFRT and HFRT for the treatment of LACC. The HFRT could be considered for high volume limited resource settings.
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Kidd LC, Lee M, Lee Z, Epstein M, Liu S, Rangel E, Ahmed N, Sotelo R, Hemal A, Eun DD. A Multi-Institutional Experience with Robotic Vesicovaginal and Ureterovaginal Fistula Repair After Iatrogenic Injury. J Endourol 2021; 35:1659-1664. [PMID: 33787314 DOI: 10.1089/end.2020.0993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: To describe our multi-institutional experience with robotic repair of iatrogenic urogynecologic fistulae (UGF), including vesicovaginal fistulae (VVF) and ureterovaginal fistulae (UVF). Methods: We performed a retrospective review identifying patients who underwent robotic repair of VVF and UVF between January 2010 and May 2019. All patients failed conservative management with Foley catheter or upper tract drainage (ureteral stent and/or nephrostomy tube), respectively. Patient demographics and perioperative outcomes were analyzed. Success was defined as no vaginal leakage of urine postoperatively, in the absence of drains, catheters, or stents. Results: Of 34 patients, 22/34 (65%) had VVF and 12/34 (35%) had UVF repair. VVF etiology included radiation (1/22, 4.5%) and surgery (21/22, 95.5%). Four of 22 (18%) had undergone prior repair attempt. Median console time was 187 minutes (interquartile range [IQR]: 151-219), estimated blood loss (EBL) was 50 mL (IQR: 50-93), and median length of stay (LOS) was 1 day (IQR: 1-2). Two of 22 (9%) patients had a postoperative complication. At mean follow-up of 28.9 months, 20/22 (91%) VVF cases were clinically effective. UVF etiology was gynecologic surgery in all cases; 8/12 (67%) were left-sided, 4/12 (33%) were right-sided. None was repeat repairs. Two of 12 (17%) underwent ureteroureterostomy, and 10/12 (83%) had reimplant. Median console time was 160 minutes (IQR: 133-196), EBL was 50 mL (IQR: 50-112), and LOS was 1 day (IQR: 1-1). No complications were encountered. At mean follow-up of 29.3 months, 100% of UVF repairs were effective. Conclusions: Robotic repair of iatrogenic UGF may be effectively performed with low complication rates by experienced urologic surgeons.
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Affiliation(s)
- Laura C Kidd
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Matthew Lee
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Ziho Lee
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Matthew Epstein
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Shuo Liu
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Enanyeli Rangel
- Department of Urology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Nahrin Ahmed
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Rene Sotelo
- Department of Urology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Daniel D Eun
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Feasibility of ureter delineation and dose recording in the assessment of ureteric stenosis during brachytherapy for cervical cancer. Brachytherapy 2021; 20:755-764. [PMID: 33926834 DOI: 10.1016/j.brachy.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Ureteric stenosis is the commonest complication to affect the ureter after radiotherapy for cervical cancer; despite this ureters are not contoured as organs at risk and limited dosimetric data exist for them. METHODS/MATERIALS Bilateral ureters were retrospectively delineated on brachytherapy planning imaging for patients treated for cervical cancer between 2014 and 2019. Ureteric stenosis toxicity data and D2cc, D1cc, D0.1cc of the right and left ureter were collated. Ureter V80, V100, V120, and V150 were also analyzed. Univariate analysis was performed to identify predictors of high ureter dose and ureteric stenosis. RESULTS 95 patients were identified and 190 ureters contoured on brachytherapy planning imaging, with a median follow-up duration of 24 months (IQR23.7). 4.2% (4) of patients had grade 3/4 ureteric stenosis. Mean ureter D0.1cc, D1.0cc and D2.0cc on the right were 80.4Gy (±28.9), 56.2Gy (±7.2) and 52.8Gy (±7.6), and on the left were 75.6Gy (±14.6), 54.3Gy (±5.5) and 52.7Gy (±5.5) respectively. Significantly higher ureter doses were present in patients with baseline hydronephrosis (p < 0.002) and interstitial needle use (p = 0.047). Ureters affected by ureteric stenosis received D0.1cc doses between 60-98Gy. 10-14% received point doses in excess of 150% of the prescribed dose (7Gy) with no resulting ureteric stenosis. No significant difference in D0.1cc was found in patients with or without ureteric stenosis. CONCLUSIONS It is feasible to accurately contour ureters on brachytherapy planning imaging. Baseline hydronephrosis and interstitial needle use contribute to higher ureter doses. No association between dose and ureteric stenosis was found.
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Cai J, He X, Wang H, Dong W, Zhang Y, Zhao J, Willborn KC, Huang B, Wang Z, Jiang P. Topographic distribution of lymph node metastasis in patients with stage IB1 cervical cancer: an analysis of 8314 lymph nodes. Radiat Oncol 2021; 16:54. [PMID: 33743714 PMCID: PMC7981976 DOI: 10.1186/s13014-021-01781-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/10/2021] [Indexed: 11/21/2022] Open
Abstract
Background Systematic pelvic lymphadenectomy or whole pelvic irradiation is recommended for the patients with stage IB1 cervical cancer. However, the precise pattern of lymphatic tumor spread in cervical cancer is unknown. In the present study we evaluated the distribution of nodal metastases in stage IB1 cervical cancer to explore the possibilities for tailoring cancer treatment. Methods A total of 289 patients with cervical cancer of stage IB1, according to FIGO 2009, were retrospectively analyzed. All patients underwent laparoscopic radical hysterectomy (Querleu and Morrow type C2) and systematic pelvic lymphadenectomy with or without para-aortic lymphadenectomy (level 2 or level 3 according to Querleu and Morrow) from October 2014 to December 2017. Lymph nodes removed from 7 well-defined anatomical locations as well as other tissues were examined histopathologically, and typed, graded, and staged according to the WHO/IARC classification. Results Totally 8314 lymph nodes were analyzed with the average number of 31.88 ± 10.34 (Mean ± SD) lymph nodes per patient. Nodal metastases were present in 44 patients (15.22%). The incidence of lymphatic spread to different anatomic sites ranged from 0% (presacral) to 30.92% (obturator nodes). Tumor size above 2 cm, histologically proven lymphovascular space involvement (LVSI) and parametrial invasion were shown to be significantly correlated with the higher risk of lymphatic metastasis, while obesity (BMI ≥ 25) was independently negatively associated with lymphatic metastases.
Conclusions The incidence of lymph node metastasis in patients with stage IB1 cervical cancer is low but prognostically relevant. Individual treatment could be considered for the selected low-risk patients who have smaller tumors and obesity and lack of the parametrial invasion or LVSI.
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Affiliation(s)
- Jing Cai
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Xiaoqi He
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Hongbo Wang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Weihong Dong
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Yuan Zhang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Jing Zhao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Kay C Willborn
- University Clinic for Medical Radiation Physics, Medical Campus Pius-Hospital, Carl von Ossietzky University Oldenburg, Georgstrasse 12, 26121, Oldenburg, Germany
| | - Bangxing Huang
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zehua Wang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Ping Jiang
- University Clinic for Medical Radiation Physics, Medical Campus Pius-Hospital, Carl von Ossietzky University Oldenburg, Georgstrasse 12, 26121, Oldenburg, Germany.
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11
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Rodríguez-López JL, Ling DC, Keller A, Kim H, Mojica-Márquez AE, Glaser SM, Beriwal S. Ureteral stenosis after 3D MRI-based brachytherapy for cervical cancer – Have we identified all the risk factors? Radiother Oncol 2021; 155:86-92. [DOI: 10.1016/j.radonc.2020.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
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Glaser SM, Mohindra P, Mahantshetty U, Beriwal S. Complications of intracavitary brachytherapy for gynecologic cancers and their management: A comprehensive review. Brachytherapy 2021; 20:984-994. [PMID: 33478905 DOI: 10.1016/j.brachy.2020.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Intracavitary gynecologic brachytherapy in the form of tandem-based brachytherapy and vaginal cylinder-based brachytherapy represents a fundamental component of the treatment of women with cervical or uterine cancer due to the ability to deliver a therapeutic dose of radiation with sharp dose falloff. This results in highly effective treatment in terms of oncologic outcomes with an overall favorable toxicity profile. Still, complications and side effects of brachytherapy do exist. While advances in brachytherapy techniques have led to a significant decrease in the rates of toxicity, a thorough understanding of the potential complications is crucial to ensuring optimal outcomes for women with gynecologic cancer undergoing brachytherapy. Use of equivalent dose at 2 Gy per fraction (EQD2) models has allowed incorporation of external beam radiotherapy dose to the brachytherapy dose leading to development of consolidated dose constraints for organs-at-risk in the modern era. This manuscript offers a comprehensive review of potential complications associated with intracavitary brachytherapy for gynecologic cancer including predictive factors, mitigation tactics, and management strategies.
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Affiliation(s)
- Scott M Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA.
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
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A phase III randomised trial of trans-abdominal ultrasound in improving application quality and dosimetry of intra-cavitary brachytherapy in locally advanced cervical cancer. Gynecol Oncol 2020; 160:375-378. [PMID: 33293047 DOI: 10.1016/j.ygyno.2020.11.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/27/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Intra-cavitary brachytherapy (ICB) remains an integral part of radiotherapy treatment in cervical cancer. Two-dimensional X ray point-based planning remains common and blind insertion leads to uterine perforations and higher toxicity. We conducted a randomised controlled trial of using trans-abdominal ultrasound in performing ICB to reduce perforation and organ at risk doses. PATIENT AND METHODS The present study is a phase III open label randomised controlled trial of ultrasound guided ICB conducted on invasive cervical cancer patients. Patients were randomised by a simple computer-generated randomization chart into Arm A (No Ultrasound guidance) and Arm B (ICB with ultrasound guidance). The uterine perforation rates, tandem length change rates, bladder doses, rectal dose and procedure times were compared. Fischer exact test was used to compare the arms and p value <0.05 considered significant. RESULTS A total of 160 patients were randomised. With US assistance, the uterine perforation rate was 1.25% (n = 1). In the non-US assistance arm the perforation rate was 12.5% (n = 10) (p = 0.005). Mean time to complete the entire procedure was significantly shortened from 26 min to 19 min favouring the US arm (p = 0.001). Dosimetric assessment between the two groups showed significant decrease in dose received by the various organs at risk with US assistance. CONCLUSION The present study confirms significant improvement in application quality as well as dosimetry with reduction in procedure time. Trans-Abdominal US should be routinely used for ICB procedures, particularly in resource limited settings.
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Impact of intracavitary brachytherapy technique (2D versus 3D) on outcomes of cervical cancer: a systematic review and meta-analysis. Strahlenther Onkol 2020; 196:973-982. [DOI: 10.1007/s00066-020-01658-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/13/2020] [Indexed: 11/26/2022]
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15
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Ye F, Ning J, Fardous Z, Katsube T, Li Q, Wang B. Citrulline, A Potential Biomarker of Radiation-Induced Small Intestine Damage. Dose Response 2020; 18:1559325820962341. [PMID: 33013253 PMCID: PMC7513408 DOI: 10.1177/1559325820962341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/20/2020] [Accepted: 08/31/2020] [Indexed: 12/25/2022] Open
Abstract
Radiation damage assessment of the small intestine is important in nuclear accidents or routine radiotherapy of abdominal tumors. This article reviews the clinical symptoms and molecular mechanisms of radiation-induced small intestinal damage and summarizes recent research on biomarkers of such damage. Citrulline is the most promising biomarker for the evaluation of radiation-induced small intestinal damage caused by radiotherapy and nuclear accidents. This article also summarizes the factors influencing plasma citrulline measurement investigated in the latest research, as well as new findings on the concentration of citrulline in saliva and urine after different types of radiation.
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Affiliation(s)
- Fei Ye
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, People’s Republic of
China
| | - Jing Ning
- Gansu Provincial Hospital, Lanzhou, People’s Republic of China
| | - Zeenath Fardous
- Institute of Food and Radiation
Biology, Atomic Energy Research Establishment, Bangladesh Atomic Energy
Commission, Dhaka, Bangladesh
| | - Takanori Katsube
- National Institute of Radiological Sciences, National Institutes
for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Qiang Li
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, People’s Republic of
China
| | - Bing Wang
- National Institute of Radiological Sciences, National Institutes
for Quantum and Radiological Science and Technology, Chiba, Japan
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16
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Toia B, Pakzad M, Hamid R, Greenwell T, Ockrim J. Surgical outcomes of vesicovaginal fistulae in patients with previous pelvic radiotherapy. Int Urogynecol J 2020; 31:1381-1385. [PMID: 31989199 DOI: 10.1007/s00192-019-04217-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/16/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vesicovaginal fistulae (VVF) repair success rates for simple surgical fistulae are high, but constitute a significantly greater challenge when occurring in a radiotherapy field. We aim to evaluate the causes, assessment, closure rates and functional outcomes of VVF surgery in patients with previous radiotherapy. METHODS Data on all VVF repairs were collected prospectively. A retrospective review of outcomes in those with VVF performed between 2009 and 2018 was carried out. Details including time from radiotherapy, pre-operative assessments, approach to surgery and functional outcome were analysed. RESULTS Twenty women with VVFs were identified. The mean age was 59 (range 25-88) years. Primary malignancy was cervical in 16 women, with the remaining 4 women having ovarian, urethral, endometrial and rectal cancer respectively. All women had external beam radiotherapy with 6 (30%) undergoing boosted brachytherapy. Mean interval between radiotherapy and fistula repair was 19 (range 0-40) years. Fistulae arose spontaneously in 14 patients, whereas 6 occurred following a further surgical intervention.Closure was attempted vaginally in 7 women and abdominally in 1, whereas 12 had a primary diversion owing to significant bladder contracture and ureteric involvement. The closure rate in those attempted was 62.5%, 40% in those with spontaneous fistulae compared with 100% for post-surgical fistulae, but only 20% for the total cohort. CONCLUSIONS Closure of VVF is a significant challenge, with an initial success rate of 20% and an overall success rate of only 25%. Seventy percent required primary or secondary urinary diversion. Vaginal surgery was utilised in the majority to try to avoid a hostile pelvis, but the surgical approach should be tailored to individual circumstances.
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Affiliation(s)
- Bogdan Toia
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland Street, London, W1G 8PH, UK.
| | - Mahreen Pakzad
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland Street, London, W1G 8PH, UK
| | - Rizwan Hamid
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland Street, London, W1G 8PH, UK
| | - Tamsin Greenwell
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland Street, London, W1G 8PH, UK
| | - Jeremy Ockrim
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland Street, London, W1G 8PH, UK
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Suryadevara A, Talluri AK, Alluri KR, Vasundhara E, Kumar S, Madhusudhana Sresty NVN. A Dosimetric Analysis of the Rectal Doses in Intracavitary Brachytherapy of Carcinoma Cervix: A Prospective Study from a Single Institute. J Med Phys 2020; 44:287-291. [PMID: 31908389 PMCID: PMC6936195 DOI: 10.4103/jmp.jmp_50_19] [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: 06/15/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Carcinoma cervix is a common gynecologic malignancy in India and is treated with radical chemoradiation where intracavitary brachytherapy (ICR) is an integral part. In ICR of cervix, the two-dimensional (2D) point-based dosimetry cervix is the most common method used in high-volume centers with rectal dose calculation at modified ICRU rectal point with rectal wire placement. The rectal dose measurement using this method underestimates the dose to the rectum, and rectal dose also varies with the type of applicator used. The aim of our study is to compare the rectal dose calculated by ICRU 38 method versus rectal dose calculated by the rectal wire method using Henschke applicator. Materials and Methods: This is a single-institute, dosimetric comparison study done prospectively. Fifty patients were planned for ICR after 2D orthogonal radiograph-based, computer planning by iridium 192 high-dose rate remote afterloading technique after placing the appropriate Henschke applicator. The vaginal packing was done using sterile gauze with contrast material for defining the ICRU 38 rectal point, and a rectal wire was placed for the modified ICRU rectal point. Rectal doses were calculated by both the methods and compared. Results: The modified ICRU rectal point recorded a lower rectal dose (mean of 25%) compared to ICRU 38 rectal point in the study patients. There were ten patients (20%) with either too much or too little contrast material which made the visualization of the rectal point and radiation planning difficult. P value by paired t-test method was 0.0001, which was statistically significant. Conclusion: The modified ICRU rectal point is easier to visualize than ICRU 38 method (100% vs. 80%) for dosimetry, but it underestimates the rectal doses when compared to ICRU 38 rectal point. There needs to be a correction factor applied (25% in our study for Henschke applicator) when evaluating the rectal doses calculated by rectal wire method, to reduce the rectal toxicity.
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Affiliation(s)
- Aparna Suryadevara
- Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Anil Kumar Talluri
- Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Krishnam Raju Alluri
- Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - E Vasundhara
- Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Sudhakar Kumar
- Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - N V N Madhusudhana Sresty
- Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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Small bowel dose in subserosal tandem insertion during cervical cancer brachytherapy. Med Dosim 2020; 45:e1-e9. [DOI: 10.1016/j.meddos.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/21/2019] [Accepted: 11/21/2019] [Indexed: 11/17/2022]
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Neulander EZ, Rivera I, Kaneti J, Wajsman Z. Ureterolysis with ureterotomy and omental sleeve wrap in patients with radiation induced pelvic retroperitoneal fibrosis. Cent European J Urol 2019; 72:307-311. [PMID: 31720035 PMCID: PMC6830484 DOI: 10.5173/ceju.2019.1965] [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: 05/31/2019] [Revised: 07/28/2019] [Accepted: 08/21/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction Secondary retroperitoneal fibrosis (RPF) due to pelvic radiation alone or together with pelvic surgery is one of the causes of obstructive renal failure. Ureteral obstruction is caused by ischemic stricture and encasement by fibrotic tissue. Endo-ureterotomy alone, without vascular supply, is not successful in these cases. Material and methods We present eleven cases of ureteral obstruction due to radiation and surgery induced RPF. Seven patients had radiation therapy with or without radical hysterectomy and three patients had anterior resection of the rectum with pre-emptive radiation and one patient had anal cancer treated with local excision and radiation therapy. Nine of the eleven patients had bilateral ureteral obstruction. Open ('intubated') stented ureterotomy and omental sleeve wrap was performed. In one patient, Boari flap ureteroneocystostomy was necessary. Results Of the eleven patients (twenty renal units) we succeeded in nine patients (eighteen renal units). In two patients with bilateral ureteral obstruction, we were able to reestablish ureteral patency in only one renal unit each. Conclusions Ureterolysis with ureterotomy and omental sleeve wrap is a valid surgical approach for alleviation of ureteral ischemic obstruction due to secondary retroperitoneal fibrosis caused by radiation alone or together with pelvic surgery.
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Affiliation(s)
- Endre Zoltan Neulander
- Ben Gurion University, Soroka University Medical Center, Department of Urology, Beer Sheva, Israel
| | - Inoel Rivera
- University of Florida, Department of Urology, USA
| | - Jacob Kaneti
- Ben Gurion University, Soroka University Medical Center, Department of Urology, Beer Sheva, Israel
| | - Zev Wajsman
- University of Florida, Department of Urology, USA
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Musa AE, Shabeeb D, Alhilfi HSQ. Protective Effect of Melatonin Against Radiotherapy-Induced Small Intestinal Oxidative Stress: Biochemical Evaluation. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E308. [PMID: 31242652 PMCID: PMC6631393 DOI: 10.3390/medicina55060308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/21/2019] [Accepted: 06/21/2019] [Indexed: 01/06/2023]
Abstract
Background and Objectives: Radiation enteritis is a common side effect after radiotherapy for abdominal and pelvic malignancies. The aim of the present study was to investigate the protective effect of melatonin, known for its free radical scavenging ability, against radiotherapy-induced small intestinal oxidative damage. Materials and Methods: Thirty male Wistar rats were randomly assigned to six groups (5 rats in each) as follows: Group I (control group) rats received neither radiation nor melatonin; group II rats received only 8 Gy single dose of gamma radiation to their abdomen and pelvis regions; group III (administered with only 50 mg/kg melatonin); group IV (administered with only 100 mg/kg melatonin); group V (50 mg/kg melatonin + 8 Gy radiation), group VI (100 mg/kg melatonin + 8 Gy radiation). All rats were sacrificed after 5 days for biochemical assessments of their intestinal tissues. Results: Treatment with melatonin post irradiation significantly reduced malondialdehyde (MDA) levels as well as increased both superoxide dismutase (SOD) and catalase (CAT) activities of the irradiated intestinal tissues. In addition, melatonin administration with different doses pre irradiation led to protection of the tissues. Moreover, the 100 mg/kg dose was more effective compared to 50 mg/kg. Conclusions: The results of our study suggest that melatonin has a potent protective effect against radiotherapy-induced intestinal damage, by decreasing oxidative stress and increasing antioxidant enzymes. We recommend future clinical trials for more insights.
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Affiliation(s)
- Ahmed Eleojo Musa
- Department of Medical Physics, Tehran University of Medical Sciences (TUMS), International Campus, Tehran 1416753955, Iran.
- Research Center for Molecular and Cellular Imaging, TUMS, Tehran 1416753955, Iran.
| | - Dheyauldeen Shabeeb
- Al-Sadder Teaching Hospital, Department of Neurophysiology, Misan 62010, Iraq.
- University of Misan, Faculty of Medicine, Department of Physiology, Misan 62010, Iraq.
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Fokdal L, Tanderup K, Pötter R, Sturdza A, Kirchheiner K, Chargari C, Jürgenliemk-Schulz IM, Segedin B, Tan LT, Hoskin P, Mahantshetty U, Bruheim K, Rai B, Kirisits C, Lindegaard JC. Risk Factors for Ureteral Stricture After Radiochemotherapy Including Image Guided Adaptive Brachytherapy in Cervical Cancer: Results From the EMBRACE Studies. Int J Radiat Oncol Biol Phys 2019; 103:887-894. [DOI: 10.1016/j.ijrobp.2018.11.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/10/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022]
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Radiothérapie guidée par l’image des cancers gynécologiques. Cancer Radiother 2018; 22:608-616. [DOI: 10.1016/j.canrad.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/26/2018] [Indexed: 11/24/2022]
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23
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Zwaans BMM, Lamb LE, Bartolone S, Nicolai HE, Chancellor MB, Klaudia SW. Cancer survivorship issues with radiation and hemorrhagic cystitis in gynecological malignancies. Int Urol Nephrol 2018; 50:1745-1751. [PMID: 30132277 DOI: 10.1007/s11255-018-1970-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Given that more cancers are being diagnosed earlier and that treatment of cancer is improving, health issues of cancer survivors are becoming more common and apparent. Pelvic radiation therapy for the treatment of gynecological cancers can lead to long-term collateral damage to the bladder, a condition termed radiation cystitis (RC). Late sequelae may take many years to develop and include incontinence and pain as well as hematuria. RC is a rare but potentially life-threatening condition for which there are few management and treatment options. METHODS There are limited data in the literature regarding the effects of radiation on the bladder after gynecological cancer therapy and we hereby review the literature on cancer survivorship issues of pelvic radiation for gynecology literature. RESULTS Treatment options are available for patients with radiation-induced hemorrhagic cystitis. However, most treatments are risky or only effective for a short timeframe and no therapy is currently available to reverse the disease progress. Furthermore, no standardized guidelines exist describing preferred management options. Common therapies include hyperbaric oxygen therapy, clot evacuation, fulguration, intravesical instillation of astringent agents, and surgery. Novel developing strategies include Botulinum Toxin injections and liposomal-tacrolimus instillations. These treatments and strategies are discussed. CONCLUSIONS In this review, we will present current and advanced therapeutic strategies for RC to help cancer survivors deal with long-term bladder health issues.
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Affiliation(s)
- Bernadette M M Zwaans
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Laura E Lamb
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Sarah Bartolone
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Heinz E Nicolai
- Departamento di Urología, Universidad de Chile, Santiago, Chile.,Hospital Clínico San Borja Arriarán, Santiago, Chile
| | - Michael B Chancellor
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, USA. .,Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
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Fokdal L, Pötter R, Kirchheiner K, Lindegaard JC, Jensen NBK, Kirisits C, Chargari C, Mahantshetty U, Jürgenliemk-Schulz IM, Segedin B, Hoskin P, Tanderup K. Physician assessed and patient reported urinary morbidity after radio-chemotherapy and image guided adaptive brachytherapy for locally advanced cervical cancer. Radiother Oncol 2018; 127:423-430. [PMID: 29784450 DOI: 10.1016/j.radonc.2018.05.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 04/30/2018] [Accepted: 05/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The EMBRACE study is a prospective multi-institutional study on MRI guided adaptive brachytherapy (IGABT) in locally advanced cervix cancer (LACC). This analysis describes early to late urinary morbidity assessed by physicians and patients (PRO). MATERIAL AND METHODS A total of 1176 patients were analysed. Median follow up (FU) was 27 (1-83) months. Morbidity (CTCAE v.3) and PRO (EORTC QLQ-C30&CX24) was prospectively assessed at baseline (BL), and during FU. RESULTS The most frequent symptoms were frequency/urgency, incontinence, and cystitis with grade 2-4 prevalence rates of 4.3%, 5.0% and 1.7% and grade 1-4 prevalence rates of 24.5%, 16.1% and 5.8% at 3-years. The most frequent PRO endpoints were "urinary frequency" and "leaking of urine". Prevalence of "Quite a bit" or "very much" bother fluctuated from 14.0% to 21.5% for "frequency", while "leaking of urine" increased from 4.6% at BL to 9.3% at 3-years. Actuarial 3-year incidence of grade 3-4 urinary morbidity was 5.3% with most events being urinary frequency, incontinence and ureteral strictures. Grade 3-4 fistula, bleeding, spasm and cystitis were all <1.0% at 3/5-years. No grade 5 toxicity occurred. CONCLUSION Urinary grade 3-4 morbidity with IGABT was limited. Urinary morbidity grade 2-4 comprises mainly frequency/urgency, incontinence and cystitis and has considerable prevalence in PRO. Various urinary morbidity endpoints have different patterns of manifestation and time course.
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Affiliation(s)
- Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark.
| | - Richard Pötter
- Department of Radiation Oncology, Medical University of Vienna, Austria
| | | | | | | | | | | | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | | | - Barbara Segedin
- Department of Oncology, Institute of Oncology Ljubljana, Slovenia
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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Appropriate magnetic resonance imaging techniques for gross tumor volume delineation in external beam radiation therapy of locally advanced cervical cancer. Oncotarget 2018. [PMID: 29515794 PMCID: PMC5839375 DOI: 10.18632/oncotarget.24071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Accurate delineation of the gross tumor volumes (GTV) is a prerequisite for precise radiotherapy planning and delivery. Different MRI sequences have different advantages and limitations in their ability to discriminate primary cervical tumor from normal tissue. The purpose of this work is to determine appropriate MRI techniques for GTV delineation for external-beam radiation therapy of locally advanced cervical cancer (LACC). Materials and Methods GTVs were delineated on the MRI, CT, and PET images acquired for 23 LACC patients in treatment positions to obtain GTVs on CT (GTV-CT), on various MRI sequences including T1 (GTV-T1), T2 (GTV-T2), T1 with fat suppression and contrast (GTV-T1F+), DWI-ADC (GTV-ADC) and on PET were generated using the threshold of 40% of maximum SUV (GTV-SUV40%) as well as SUV of 2.5 (GTV-SUV2.5). MRI, CT and PET were registered for comparison. The GTVs defined by MRI were compared using the overlap ratio (OR) and relative volume ratio (RVR). The union of GTV-T2 and GTV-ADC was generated to represent the MRI-based GTV (GTV-MRI). Results The differences between GTV-T2 and other MRI GTVs are significant (P < 0.05). The average ORs for GTV-T1, GTV-T1F+, and GTV-ADC related to GTV-T2 were 86.3%, 81.6%, and 61.6% with the corresponding average RVRs 113.8%, 112.3% and 77.2%, respectively. There is no significant difference between GTV-T1 and GTV-T1F+. GTV-ADC was generally smaller than GTV-T2, however, encompassed suspicious regions that are uncovered in GTV-T2 (up to 16% of GTV-T2) because of different imaging mechanisms. There was significant difference between GTV-MRI, GTV-SUV2.5, GTV-SUV40%, and GTV-CT. On average, GTV-MRI is 18.4% smaller than GTV-CT. Conclusions MRI provides improved visualization of disease over CT or PET for cervical cancer. The GTV from the union of GTV-T2 and GTV-ADC provides a reasonable GTV including tumor region defined anatomically and functionally with MRI and substantially reduces the conventional GTV defined on CT.
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[Rectal toxicity prediction based on accurate rectal surface dose summation for cervical cancer radiotherapy]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017. [PMID: 29292256 PMCID: PMC6744008 DOI: 10.3969/j.issn.1673-4254.2017.12.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To propose arectal toxicity prediction method based on deformable surface dose accumulation. METHODS The clinical data were collected retrospectively from 42patients receiving radiotherapy for cervical cancer. With the first fraction as the reference, the other fractions of rectum surface were registered to the reference fraction to obtain the deformation vector fields (DVFs), which were used to deform and sum the fractional rectal doses to yield the cumulative rectal dose. The cumulative rectal dose was flattened via 3D-2D mapping to generate a 2D rectum surface dose map. Two dosimetric features, namely DVPs and DGPs were extracted. Logistic regression embedded with sequential forward feature selection was used as the prediction model. The predictive performance was evaluated in terms of the accuracy, sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve (AUC). RESULTS Significant improvements for rectum surface DIR were achieved. The best predictive results were achieved by using both DVPs and DGPs as the features with a sensitivity of 79.5%, a specificity of 81.3% and an AUC of 0.88. CONCLUSION The proposed method is feasible for predicting clinical rectal toxicity in patients undergoing radiotherapy for cervical cancer.
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Misra S, Lal P, Kumar Ep S, Rastogi N, Tiwari A, Singh S, Das KJM, Kumar S. Comparative assessment of late toxicity in patients of carcinoma cervix treated by radiotherapy versus chemo-radiotherapy - Minimum 5 years follow up. Cancer Treat Res Commun 2017; 14:30-36. [PMID: 30104006 DOI: 10.1016/j.ctarc.2017.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 11/20/2017] [Accepted: 11/29/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND A randomised trial was carried out comparing chemo-radiation (CTRT) vs. radiotherapy (RT) in patients of carcinoma cervix and showed similar rates of pelvic disease control, disease free survival and overall survival. Late toxicity is presented. METHODS Between December 2000 and July 2006, 180 patients of carcinoma cervix were randomly assigned to RT + weekly cisplatin (n = 94) or RT alone (n = 86). Late toxicity was prospectively scored using RTOG criteria in 156 evaluable patients, 79 and 77 respectively and is presented as crude incidence for rectum, bladder, small intestine, vagina, skin and bone and also as actuarial incidence for rectum and bladder. RESULTS The median follow up of surviving patients was 10.4 years (minimum - 6.5 years). Crude incidence, CTRT vs. RT, of late toxicities were: rectal (7.5% vs. 5%, p = 0.22), bladder (15% vs. 10.4%, p = 0.76), small bowel (3% vs. 1.2%, p = 0.51), vagina (25% vs. 35%, p = 0.35) while the actuarial risk of grades 3-5 rectal and bladder toxicities by 5 years were 13% vs. 10% (p = 0.698) and 16% vs. 14.8% (p = 0.783) respectively. Bladder toxicity appeared later then rectal toxicity (median 49.4 vs. 21.4 months). Severe bone toxicity (fractures) were higher in the CTRT arm, 5% vs. 0%, p = 0.018. On multivariate analysis vaginal involvement (p = 0.016) and bulky tumor (p = 0.020) were associated with severe vaginal morbidity while rectal point dose > 80% (p = 0.040) was associated with a higher incidence of rectal toxicity. CONCLUSION Bone toxicity was significantly increased by addition of CT to RT and patients continued to experience toxicity at longer periods of follow up albeit disease free.
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Affiliation(s)
- Shagun Misra
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India.
| | - Punita Lal
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - Saibish Kumar Ep
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - Neeraj Rastogi
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - Anu Tiwari
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - Shalini Singh
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - K J Maria Das
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
| | - Shaleen Kumar
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
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Santos DA, Alseidi A, Shannon VR, Messick C, Song G, Ledet CR, Lee H, Ngo-Huang A, Francis GJ, Asher A. Management of surgical challenges in actively treated cancer patients. Curr Probl Surg 2017; 54:612-654. [DOI: 10.1067/j.cpsurg.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Cao F, Ma TH, Liu GJ, Wen YL, Wang HM, Kuang YY, Qin S, Liu XY, Huang BJ, Wang L. Correlation between Disease Activity and Endorectal Ultrasound Findings of Chronic Radiation Proctitis. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2182-2191. [PMID: 28755790 DOI: 10.1016/j.ultrasmedbio.2017.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/03/2017] [Accepted: 06/21/2017] [Indexed: 06/07/2023]
Abstract
The aim of this study was to summarize the imaging features of chronic radiation proctitis (CRP) on endorectal ultrasound (ERUS) and investigate the value of ERUS in the evaluation of disease activity. 40 CRP patients and 30 control patients were investigated by ERUS. Rectal wall thickness and layers, ulcers and rectovaginal fistulas were evaluated by B-mode ultrasound. Power Doppler imaging was used to evaluate the vascularity of the rectal wall using a semiquantitative score. Disease activity was calculated according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 (CTCAE 4.0). Imaging findings for patients with mild and severe CRP were compared. For 30 patients in the control group, the average maximum thickness of the rectal wall was 3.07 ± 0.73 mm, with all exhibiting typical wall stratification and level 0 vascularity. For the 40 CRP patients, there was marked thickening of the rectal wall (average thickness = 9.42 ± 1.94 mm), which was significantly thicker than in the control group (p < 0.05). The rectal walls of the mild group were significantly thinner than those of the severe group (8.71 ± 1.67 mm vs. 10.00 ± 2.00 mm, p < 0.05). Among the 22 severe cases, 19 cases (19/22, 86.4%) exhibited hyper-vascularity (level IV) or blurred wall stratification (including hypo-echoic submucosa, ulcer and fistula); 12 of the 18 mild cases (166.7%) exhibited a vascularity of level III and typical wall stratification. A significant association (p < 0.05) was observed between stratification and vascularity of the rectal wall and CRP activity. When ERUS findings of blurred rectal wall stratification or increasing vascularity (level IV) were used to evaluate CRP activity, the sensitivity was 86.4% (95% confidence interval: 64.0-96.4) and the specificity was 66.7% (95% confidence interval: 41.2-85.6). Thickening of the rectal wall, blurred wall stratification and increased vascularity are characteristic ERUS findings of CRP. ERUS is helpful in the comprehensive evaluation of disease activity and may provide objective evidence during treatment planning and follow-up.
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Affiliation(s)
- Fei Cao
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Teng-Hui Ma
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Guang-Jian Liu
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yan-Ling Wen
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Huai-Ming Wang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ying-Yi Kuang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Si Qin
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiao-Yin Liu
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Bin-Jie Huang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Wang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Thomas KM, Maquilan G, Stojadinovic S, Medin P, Folkert MR, Albuquerque K. Reduced toxicity with equivalent outcomes using three-dimensional volumetric (3DV) image–based versus nonvolumetric point–based (NV) brachytherapy in a cervical cancer population. Brachytherapy 2017; 16:943-948. [DOI: 10.1016/j.brachy.2017.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/04/2017] [Accepted: 05/01/2017] [Indexed: 11/25/2022]
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Rectal separation using hydroxypropyl methylcellulose in intracavitary brachytherapy of cervical cancer: an innovative approach. J Contemp Brachytherapy 2016; 8:399-403. [PMID: 27895681 PMCID: PMC5116447 DOI: 10.5114/jcb.2016.62951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE This study was initiated to prove feasibility of hydrogel application in recto-vaginal space in intracavitary brachytherapy (ICBT) of cervical cancer in order to reduce rectal toxicity. MATERIAL AND METHODS In a case of stage IIB cervical cancer, after external beam radiotherapy (EBRT), we planned ICBT 7 Gy × 3 fractions. In 1st fraction (Plan 1), due to narrow separation between rectum and cervix (0.18 cm), only 5 Gy was delivered at point A (with high-risk clinical target volume [HR-CTV] D90 5.94 Gy, intermediate risk clinical target volume [IR-CTV] D90 4.54 Gy, rectum D2cc 5.72 Gy, bladder D2cc 5.52 Gy, and sigmoid colon 5.82 Gy). In 2nd fraction (Plan 2), interstitial brachytherapy (ISBT) was attempted. For the prescription of 5 Gy, we get dose levels almost similar to the 1st insertion: HR-CTV D90 (6.7 Gy), IR-CTV D90 (3.06 Gy), bladder D2cc (5.7 Gy), rectum D2cc (4.8 Gy), sigmoid colon D2cc (1.3 Gy) (separation = 0.23 cm). During 3rd fraction (Plan 3), prior doing interstitial insertion, we instilled 50 cc of hydroxypropyl methylcellulose (Viscomet®) up to the tip of recto-vaginal septum. A repeat computed tomography (CT) scan was done 4 hours after Plan 3 treatment and it was re-planned (Plan 4) to find out migration of hydrogel if any and its dosimetric impact. RESULTS 9 Gy was delivered to point A with a separation of 1.1 cm in Plan 3 (with HR-CTV D90 16.4 Gy, IR-CTV D90 11.3 Gy, rectum D2cc 3.6 Gy, bladder D2cc 6.9 Gy, and sigmoid colon 2.2 Gy). We achieved an optimum cumulative EQD2 dose (HR-CTV D90 98.4 Gy, IR-CTV D90 76.1 Gy, rectum D2cc 67.7 Gy, bladder D2cc 73.2 Gy, and sigmoid colon 59.3 Gy). Hydrogel volume was decreased in Plan 4 without a major dosimetric changes. CONCLUSIONS Hydrogel instillation is a useful tool for recto-vaginal separation during cervical cancer brachytherapy. It increases therapeutic ratio without any adverse event.
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Wadi-Ramahi S, Alnajjar W, Mahmood R, Jastaniyah N, Moftah B. Failure modes and effects analysis in image-guided high-dose-rate brachytherapy: Quality control optimization to reduce errors in treatment volume. Brachytherapy 2016; 15:669-78. [DOI: 10.1016/j.brachy.2016.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/06/2016] [Accepted: 06/17/2016] [Indexed: 10/21/2022]
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Dose-volume effect relationships for late rectal morbidity in patients treated with chemoradiation and MRI-guided adaptive brachytherapy for locally advanced cervical cancer: Results from the prospective multicenter EMBRACE study. Radiother Oncol 2016; 120:412-419. [PMID: 27396811 DOI: 10.1016/j.radonc.2016.06.006] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/23/2016] [Accepted: 06/03/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To establish dose volume-effect relationships predicting late rectal morbidity in cervix cancer patients treated with concomitant chemoradiation and MRI-guided adaptive brachytherapy (IBABT) within the prospective EMBRACE study. MATERIAL AND METHOD All patients were treated with curative intent according to institutional protocols with chemoradiation and IGABT. Reporting followed the GEC-ESTRO recommendations ( [Formula: see text] , [Formula: see text] ), applying bioeffect modeling (linear quadratic model) with equieffective doses (EQD23). Morbidity was scored according to the CTC-AE 3.0. Dose-effect relationships were assessed using comparisons of mean doses, the probit model and log rank tests on event-free periods. RESULTS 960 patients were included. The median follow-up was 25.4months. Twenty point one percent of the patients had grade 1 events, 6.0% grade 2, 1.6% grade 3 and 0.1%, grade 4. The mean DICRU, [Formula: see text] , and [Formula: see text] were respectively: 66.2±9.1Gy, 72.9±11.9Gy, and 62.8±7.6Gy. Increase of dose was associated with increase in severity of single endpoints and overall rectal morbidity (grade 1-4) (p<0.001-0.026), except for stenosis (p=0.24-0.31). The probit model showed significant relationships between the [Formula: see text] , [Formula: see text] , and DICRU and the probability of grade 1-4, 2-4, and 3-4 rectal events. The equieffective [Formula: see text] for a 10% probability for overall rectal grade⩾2 morbidity was 69.5Gy (p<0.0001). After sorting patients according to 6 [Formula: see text] levels, less favorable outcome was observed in the high dose subgroups, for bleeding, proctitis, fistula, and overall rectal morbidity. A [Formula: see text] ⩾75Gy was associated with a 12.5% risk of fistula at 3years versus 0-2.7% for lower doses (p>0.001). A [Formula: see text] <65Gy was associated with a two times lower risk of proctitis than [Formula: see text] ⩾65Gy. CONCLUSIONS Significant correlations were established between late rectal morbidity, overall and single endpoints, and dose-volume ( [Formula: see text] , [Formula: see text] ) and dose-point (DICRU) parameters. A [Formula: see text] ⩽65Gy is associated with more minor and less frequent rectal morbidity, whereas a [Formula: see text] ⩾75Gy is associated with more major and more frequent rectal morbidity.
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Experiencia del Instituto Regional de Tratamiento del Cáncer en el manejo del cáncer cervicouterino con radioterapia. GACETA MEXICANA DE ONCOLOGÍA 2016. [DOI: 10.1016/j.gamo.2016.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Tanderup K, Fokdal LU, Sturdza A, Haie-Meder C, Mazeron R, van Limbergen E, Jürgenliemk-Schulz I, Petric P, Hoskin P, Dörr W, Bentzen SM, Kirisits C, Lindegaard JC, Pötter R. Effect of tumor dose, volume and overall treatment time on local control after radiochemotherapy including MRI guided brachytherapy of locally advanced cervical cancer. Radiother Oncol 2016; 120:441-446. [PMID: 27350396 DOI: 10.1016/j.radonc.2016.05.014] [Citation(s) in RCA: 226] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 05/13/2016] [Accepted: 05/16/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Currently, there is no consensus on dose prescription in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. The purpose of this study was to provide evidence based recommendations for tumor dose prescription based on results from a multi-center patient series (retroEMBRACE). MATERIALS AND METHODS This study analyzed 488 locally advanced cervical cancer patients treated with external beam radiotherapy±chemotherapy combined with IGABT. Brachytherapy contouring and reporting was according to ICRU/GEC-ESTRO recommendations. The Cox Proportional Hazards model was applied to analyze the effect on local control of dose-volume metrics as well as overall treatment time (OTT), dose rate, chemotherapy, and tumor histology. RESULTS With a median follow up of 46months, 43 local failures were observed. Dose (D90) to the High Risk Clinical Target Volume (CTVHR) (p=0.022, HR=0.967 per Gy) was significant for local control, whereas increasing CTVHR volume (p=0.004, HR=1.017 per cm3), and longer OTT (p=0.004, HR=1.023 per day) were associated with worse local control. Histology (p=0.084), chemotherapy (p=0.49) and dose rate (p=1.00) did not have significant impact on local control. Separate analyses according to stage of disease showed that dose to CTVHR, residual gross tumor volume (GTVres), and Intermediate Risk CTV (CTVIR) has significant impact on local control. CONCLUSION CTVHR dose of ⩾85Gy (D90) delivered in 7weeks provides 3-year local control rates of >94% in limited size CTVHR (20cm3), >93% in intermediate size (30cm3) and >86% in large size (70cm3) CTVHR. CTVIR and GTVres dose of ⩾60Gy and ⩾95Gy (D98) leads to similar local control. A dose of 5Gy (CTVHR) is required to compensate an increase of OTT by one week. Increased CTVHR volume by 10cm3 requires additional 5Gy for equivalent local control.
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Affiliation(s)
- Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark.
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Christine Haie-Meder
- Radiation Oncology Department, Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - Renaud Mazeron
- Radiation Oncology Department, Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - Erik van Limbergen
- Department of Radiation-Oncology, University Hospitals of Leuven, Belgium
| | | | - Primoz Petric
- Department of Radiation Oncology, National Center for Cancer Care and Research, Doha, Qatar; Division of Radiotherapy, National Institute of Oncology, Ljubljana, Slovenia
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Wolfgang Dörr
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Søren M Bentzen
- Greenebaum Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | | | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
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Dosimetric study for cervix carcinoma treatment using intensity modulated radiation therapy (IMRT) compensation based on 3D intracavitary brachytherapy technique. J Contemp Brachytherapy 2016; 8:221-32. [PMID: 27504132 PMCID: PMC4965499 DOI: 10.5114/jcb.2016.60590] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 05/24/2016] [Indexed: 11/17/2022] Open
Abstract
Purpose Intensity modulated radiation therapy (IMRT) compensation based on 3D high-dose-rate (HDR) intracavitary brachytherapy (ICBT) boost technique (ICBT + IMRT) has been used in our hospital for advanced cervix carcinoma patients. The purpose of this study was to compare the dosimetric results of the four different boost techniques (the conventional 2D HDR intracavitary brachytherapy [CICBT], 3D optimized HDR intracavitary brachytherapy [OICBT], and IMRT-alone with the applicator in situ). Material and methods For 30 patients with locally advanced cervical carcinoma, after the completion of external beam radiotherapy (EBRT) for whole pelvic irradiation 45 Gy/25 fractions, five fractions of ICBT + IMRT boost with 6 Gy/fractions for high risk clinical target volume (HRCTV), and 5 Gy/fractions for intermediate risk clinical target volume (IRCTV) were applied. Computed tomography (CT) and magnetic resonance imaging (MRI) scans were acquired using an in situ CT/MRI-compatible applicator. The gross tumor volume (GTV), the high/intermediate-risk clinical target volume (HRCTV/IRCTV), bladder, rectum, and sigmoid were contoured by CT scans. Results For ICBT + IMRT plan, values of D90, D100 of HRCTV, D90, D100, and V100 of IRCTV significantly increased (p < 0.05) in comparison to OICBT and CICBT. The D2cc values for bladder, rectum, and sigmoid were significantly lower than that of CICBT and IMRT alone. In all patients, the mean rectum V60 Gy values generated from ICBT + IMRT and OICBT techniques were very similar but for bladder and sigmoid, the V60 Gy values generated from ICBT + IMRT were higher than that of OICBT. For the ICBT + IMRT plan, the standard deviations (SD) of D90 and D2cc were found to be lower than other three treatment plans. Conclusions The ICBT + IMRT technique not only provides good target coverage but also maintains low doses (D2cc) to the OAR. ICBT + IMRT is an optional technique to boost parametrial region or tumor of large size and irregular shape when intracavitary/interstitial brachytherapy cannot be used.
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Kirchheiner K, Nout RA, Lindegaard JC, Haie-Meder C, Mahantshetty U, Segedin B, Jürgenliemk-Schulz IM, Hoskin PJ, Rai B, Dörr W, Kirisits C, Bentzen SM, Pötter R, Tanderup K. Dose-effect relationship and risk factors for vaginal stenosis after definitive radio(chemo)therapy with image-guided brachytherapy for locally advanced cervical cancer in the EMBRACE study. Radiother Oncol 2016; 118:160-6. [PMID: 26780997 DOI: 10.1016/j.radonc.2015.12.025] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/22/2015] [Accepted: 12/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE To identify risk factors for vaginal stenosis and to establish a dose-effect relationship for image-guided brachytherapy in locally advanced cervical cancer. MATERIALS/METHODS Patients from the ongoing EMBRACE study with prospectively assessed morbidity (CTCAEv3.0) at baseline and at least one follow-up were selected. Patient-, disease- and treatment characteristics were tested as risk factors for vaginal stenosis G ⩾ 2 in univariate and multivariable analyses (Cox proportional hazards model) and a dose-effect curve was deduced from the estimates. The ICRU rectum point was used to derive the recto-vaginal reference point dose. RESULTS In 630 patients included (median follow-up 24months), 2-year actuarial estimate for vaginal stenosis G ⩾ 2 was 21%. Recto-vaginal reference point dose (HR=1.025, p=0.029), external beam radiotherapy (EBRT) dose >45 Gy/25 fractions (HR=1.770, p=0.056) and tumor extension in the vagina (HR=2.259, p ⩽ 0.001) were risk factors for vaginal stenosis, adjusted for center reporting effects. Based on the model curve, the risk was 20% at 65 Gy, 27% at 75 Gy and 34% at 85 Gy (recto-vaginal reference point dose). CONCLUSION Keeping the EBRT dose at 45 Gy/25 fractions and decreasing the dose contribution of brachytherapy to the vagina decrease the risk of stenosis. A planning aim of ⩽65 Gy EQD2 (EBRT+brachytherapy dose) to the recto-vaginal reference point is therefore proposed.
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Affiliation(s)
- Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria.
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | | | | | | | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | | | | | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Wolfgang Dörr
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria; Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Austria; Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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Susko M, Craciunescu O, Meltsner S, Yang Y, Steffey B, Cai J, Chino J. Vaginal Dose Is Associated With Toxicity in Image Guided Tandem Ring or Ovoid-Based Brachytherapy. Int J Radiat Oncol Biol Phys 2015; 94:1099-105. [PMID: 26883564 DOI: 10.1016/j.ijrobp.2015.12.360] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/11/2015] [Accepted: 12/15/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE To calculate vaginal doses during image guided brachytherapy with volume-based metrics and correlate with long-term vaginal toxicity. METHODS AND MATERIALS In this institutional review board-approved study, institutional databases were searched to identify women undergoing computed tomography and/or magnetic resonance-guided brachytherapy at the Duke Cancer Center from 2009 to 2015. All insertions were contoured to include the vagina as a 3-dimensional structure. All contouring was performed on computed tomography or magnetic resonance imaging and used a 0.4-cm fixed brush to outline the applicator and/or packing, expanded to include any grossly visible vagina. The surface of the cervix was specifically excluded from the contour. High-dose-rate (HDR) and low-dose-rate (LDR) doses were converted to the equivalent dose in 2-Gy fractions using an α/β of 3 for late effects. The parameters D0.1cc, D1cc, and D2cc were calculated for all insertions and summed with prior external beam therapy. Late and subacute toxicity to the vagina were determined by the Common Terminology Criteria for Adverse Events version 4.0 and compared by the median and 4th quartile doses, via the log-rank test. Univariate and multivariate hazard ratios were calculated via Cox regression. RESULTS A total of 258 insertions in 62 women who underwent definitive radiation therapy including brachytherapy for cervical (n=48) and uterine cancer (n=14) were identified. Twenty HDR tandem and ovoid, 32 HDR tandem and ring, and 10 LDR tandem and ovoid insertions were contoured. The median values (interquartile ranges) for vaginal D0.1cc, D1cc, and D2cc were 157.9 (134.4-196.53) Gy, 112.6 (96.7-124.6) Gy, and 100.5 (86.8-108.4) Gy, respectively. At the 4th quartile cutoff of 108 Gy for D2cc, the rate of late grade 1 toxicity at 2 years was 61.2% (95% confidence interval [CI] 43.0%-79.4%) below 108 Gy and 83.9% (63.9%-100%) above (P=.018); grade 2 or greater toxicity was 36.2% (95% CI 15.8%-56.6%) below 108 Gy and 70.7% (95% CI 45.2%-96.2%) above (P=.004); and grade 3 or worse toxicity was 9.9% (95% CI 0.0%-23.6%) below 108 Gy and 30.0% (95% CI 4.7%-55.3%) above (P=.025). This association was maintained on multivariate analysis, independent of covariates such as applicator type, age, and dose rate. CONCLUSIONS Vaginal dose was associated with all grades of vaginal toxicity. Confirmation at other sites using this methodology will be necessary to establish reproducibility; however, the integration of routine calculation of vaginal dose may be warranted.
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Affiliation(s)
- Matthew Susko
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Oana Craciunescu
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Sheridan Meltsner
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Yun Yang
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Beverly Steffey
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Jing Cai
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina.
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Wu CH, Liao YJ, Shiau AC, Lin HY, Hsueh Liu YW, Hsu SM. HDR Brachytherapy Dose Distribution is Influenced by the Metal Material of the Applicator. Sci Rep 2015; 5:17863. [PMID: 26658746 PMCID: PMC4675994 DOI: 10.1038/srep17863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 11/02/2015] [Indexed: 11/25/2022] Open
Abstract
Applicators containing metal have been widely used in recent years when applying brachytherapy to patients with cervical cancer. However, the high dose rate (HDR) treatment-planning system (TPS) that is currently used in brachytherapy still assumes that the treatment environment constitutes a homogeneous water medium and does not include a dose correction for the metal material of the applicator. The primary purpose of this study was to evaluate the HDR 192Ir dose distribution in cervical cancer patients when performing brachytherapy using a metal-containing applicator. Thermoluminescent dosimeter (TLD) measurements and Monte Carlo N-Particle eXtended (MCNPX) code were used to explore the doses to the rectum and bladder when using a Henschke applicator containing metal during brachytherapy. When the applicator was assumed to be present, the absolute dose difference between the TLD measurement and MCNPX simulation values was within approximately 5%. A comparison of the MCNPX simulation and TPS calculation values revealed that the TPS overestimated the International Commission of Radiation Units and Measurement (ICRU) rectum and bladder reference doses by 57.78% and 49.59%, respectively. We therefore suggest that the TPS should be modified to account for the shielding effects of the applicator to ensure the accuracy of the delivered doses.
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Affiliation(s)
- Chin-Hui Wu
- Institute of Nuclear Engineering and Science, National Tsing Hua University, Hsinchu, Taiwan, ROC
| | - Yi-Jen Liao
- School of Medical Laboratory Science and Biotechnology, Taipei Medical University, Taipei, Taiwan, ROC
| | - An-Cheng Shiau
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan, ROC.,Medical Physics Research Center, Institute for Radiological Research, Chang Gung University. Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan, ROC
| | - Hsin-Yu Lin
- Department of Radiation Oncology, Saint Mary's Hospital Luodong, Yilan, Taiwan, ROC
| | - Yen-Wan Hsueh Liu
- Institute of Nuclear Engineering and Science, National Tsing Hua University, Hsinchu, Taiwan, ROC
| | - Shih-Ming Hsu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan, ROC.,Biophotonics and Molecular Imaging Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
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Bladder (ICRU) dose point does not predict urinary acute toxicity in adjuvant isolated vaginal vault high-dose-rate brachytherapy for intermediate-risk endometrial cancer. J Contemp Brachytherapy 2015; 7:357-62. [PMID: 26622241 PMCID: PMC4663209 DOI: 10.5114/jcb.2015.54952] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/04/2015] [Indexed: 11/19/2022] Open
Abstract
Purpose High-dose-rate brachytherapy (HDR-BT) alone is an adjuvant treatment option for stage I intermediaterisk endometrial cancer after complete surgical resection. The aim of this study was to determine the value of the dose reported to ICRU bladder point in predicting acute urinary toxicity. Oncologic results are also presented. Material and methods One hundred twenty-six patients were treated with postoperative HDR-BT 24 Gy (4 × 6 Gy) per ICRU guidelines for dose reporting. Cox analysis was used to identify variables that affected local control. The mean bladder point dose was examined for its ability to predict acute urinary toxicity. Results Two patients (1.6%) developed grade 1 gastrointestinal toxicity and 12 patients (9.5%) developed grades 1-2 urinary toxicity. No grade 3 or greater toxicity was observed. The mean bladder point dose was 46.9% (11.256 Gy) and 49.8% (11.952 Gy) for the asymptomatic and symptomatic groups, respectively (p = 0.69). After a median follow-up of 36.8 months, the 3-year local failure and 5-year cancer-specific and overall survival rates were 2.1%, 100%, and 94.6%, respectively. No pelvic failure was seen in this cohort. Age over 60 years (p = 0.48), lymphatic invasion (p = 0.77), FIGO histological grade (p = 0.76), isthmus invasion (p = 0.68), and applicator type (cylinder × ovoid) (p = 0.82) did not significantly affect local control. Conclusions In this retrospective study, ICRU bladder point did not correlate with urinary toxicity. Four fractions of 6 Gy HDR-BT effected satisfactory local control, with acceptable urinary and gastrointestinal toxicity.
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Clinical Outcomes of Computed Tomography–Based Volumetric Brachytherapy Planning for Cervical Cancer. Int J Radiat Oncol Biol Phys 2015; 93:150-7. [DOI: 10.1016/j.ijrobp.2015.04.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/14/2015] [Accepted: 04/28/2015] [Indexed: 11/24/2022]
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Nandi M, Mandal A, Asthana AK. Retrospective analysis of patients with cancer of the cervix attending a radiotherapy outpatient department: experience from a university-based hospital in eastern Uttar Pradesh, India. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2015. [DOI: 10.1080/20742835.2015.1083680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Yang J, Ding C, Zhang T, Zhang L, Lv T, Ge X, Gong J, Zhu W, Li N, Li J. Clinical features, outcome and risk factors in cervical cancer patients after surgery for chronic radiation enteropathy. Radiat Oncol 2015; 10:128. [PMID: 26047616 PMCID: PMC4462117 DOI: 10.1186/s13014-015-0433-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/28/2015] [Indexed: 11/10/2022] Open
Abstract
Background Radical hysterectomy and radiotherapy have long been mainstays of cervical cancer treatment. Early stage cervical cancer (FIGO stage IB1–IIA) is traditionally treated using radical surgery combined with radiotherapy, while locally advanced cervical cancer is treated using radiotherapy alone or chemoradiotherapy. In this retrospective study, we describe and analyse the presenting clinical features and outcomes in our cohort and evaluate possible risk factors for postoperative morbidity in women who underwent surgery for chronic radiation enteropathy (CRE). Methods One hundred sixty-six eligible cervical cancer patients who underwent surgery for CRE were retrospectively identified between September 2003 and July 2014 in a prospectively maintained database. Among them, 46 patients received radical radiotherapy (RRT) and 120 received radical surgery plus radiotherapy (RS + RT). Clinical features, postoperative morbidity and mortality, and risk factors for postoperative morbidity were analysed. Results RS + RT group patients were more likely to present with RTOG/EORTC grade III late morbidity (76.1 % vs 92.5 %; p = 0.004), while RRT group patients tended to show RTOG/EORTC grade IV late morbidity (23.9 % vs 7.5 %; p = 0.004). One hundred forty patients (84.3 %) were treated with aggressive resection (anastomosis 57.8 % and stoma 26.5 %). Overall and major morbidity, mortality and incidence of reoperation in the RRT and RS + RT groups did not differ significantly (63 % vs 64.2 % [p = 1.000], 21.7 % vs 11.7 % [p = 0.137], 6.5 % vs 0.8 % [p = 0.065] and 6.5 % vs 3.3 % [p = 0.360], respectively). However, incidence of permanent stoma and mortality during follow-up was higher in the RRT group than in the RS + RT group (44.2 % vs 12.6 % [p = 0.000] and 16.3 % vs 3.4 % [p = 0.004], respectively). In multivariate analysis, preoperative anaemia was significantly associated with overall morbidity (p = 0.015), while severe intra-abdominal adhesion (p = 0.017), ASA grades III–V (P = 0.022), and RTOG grade IV morbidity (P = 0.018) were predicators of major morbidity. Conclusions Radiation-induced late morbidity tended to be severe in the RRT group with more patients suffering RTOG/EORTC grade IV morbidity, while there were no significant differences in postoperative morbidity, mortality and reoperation. Aggressive resection was feasible with acceptable postoperative outcomes. Severe intra-abdominal adhesion, ASA grades III–V and RTOG/EORTC grade IV late morbidity contributed significantly to major postoperative morbidity.
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Affiliation(s)
- Jianbo Yang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Chao Ding
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Tenghui Zhang
- Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Southern Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Liang Zhang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Tengfei Lv
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Xiaolong Ge
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Jianfeng Gong
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. .,Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Southern Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Weiming Zhu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
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Induction Chemotherapy Followed by Concurrent Chemoradiation in the Management of Different Stages of Cervical Carcinoma: 5-year Retrospective Study. J Obstet Gynaecol India 2015; 66:372-8. [PMID: 27486284 DOI: 10.1007/s13224-015-0699-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 03/31/2015] [Indexed: 10/23/2022] Open
Abstract
AIM The data of survival for Indian cervical cancer patients treated by indigenous modifications of the protocol are scarce. The objective of this retrospective study was to analyze the efficacy and tolerability in patients of cervical carcinoma treated by neoadjuvant chemotherapy followed by concurrent chemoradiation. MATERIALS AND METHODS Three hundred and thirty two cases of squamous cell carcinoma of cervix who received 3 cycles of neoadjuvant chemotherapy followed concurrent chemoradiation were retrospectively analyzed for overall survival (OS), disease-free survival (DFS), and local pelvic control rate. RESULTS The 3-year OS and DFS were 93.7 % for stage I-B, 88.0 and 84.0 % for stage II-A, 82.8 and 79.7 % for stage II-B, 70.0 and 64.9 % for stage III-A, 59.3 and 52.4 % for stage III-B, and 53.6 and 32.1 % for stage IV-A disease. The 5-year OS and DFS rates were 93.7 and 87.5 % for stage I-B, 84.0 % for Stage II-A, 79.7 and 76.6 % for stage II-B, 67.6 and 59.5 % for stage III-A, 48.4 and 41.9 % for stage III-B, and 28.6 and 14.3 % for stage IV-A disease. CONCLUSION Neoadjuvant chemotherapy followed by concurrent chemoradiation is feasible and produces impressive disease-free and overall survival. This protocol is especially helpful for busy cancer centers with long waiting lists on radiotherapy machines.
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Hashim N, Jamalludin Z, Ung NM, Ho GF, Malik RA, Phua VCE. CT based 3-dimensional treatment planning of intracavitary brachytherapy for cancer of the cervix: comparison between dose-volume histograms and ICRU point doses to the rectum and bladder. Asian Pac J Cancer Prev 2015; 15:5259-64. [PMID: 25040985 DOI: 10.7314/apjcp.2014.15.13.5259] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND CT based brachytherapy allows 3-dimensional (3D) assessment of organs at risk (OAR) doses with dose volume histograms (DVHs). The purpose of this study was to compare computed tomography (CT) based volumetric calculations and International Commission on Radiation Units and Measurements (ICRU) reference-point estimates of radiation doses to the bladder and rectum in patients with carcinoma of the cervix treated with high-dose-rate (HDR) intracavitary brachytherapy (ICBT). MATERIALS AND METHODS Between March 2011 and May 2012, 20 patients were treated with 55 fractions of brachytherapy using tandem and ovoids and underwent post-implant CT scans. The external beam radiotherapy (EBRT) dose was 48.6 Gy in 27 fractions. HDR brachytherapy was delivered to a dose of 21 Gy in three fractions. The ICRU bladder and rectum point doses along with 4 additional rectal points were recorded. The maximum dose (DMax) to rectum was the highest recorded dose at one of these five points. Using the HDR plus 2.6 brachytherapy treatment planning system, the bladder and rectum were retrospectively contoured on the 55 CT datasets. The DVHs for rectum and bladder were calculated and the minimum doses to the highest irradiated 2cc area of rectum and bladder were recorded (D2cc) for all individual fractions. The mean D2cc of rectum was compared to the means of ICRU rectal point and rectal DMax using the Student's t-test. The mean D2cc of bladder was compared with the mean ICRU bladder point using the same statistical test .The total dose, combining EBRT and HDR brachytherapy, were biologically normalized to the conventional 2 Gy/fraction using the linear-quadratic model. (α/β value of 10 Gy for target, 3 Gy for organs at risk). RESULTS The total prescribed dose was 77.5 Gy α/β10. The mean dose to the rectum was 4.58 ± 1.22 Gy for D 2cc, 3.76 ± 0.65 Gy at D ICRU and 4.75 ± 1.01 Gy at DMax. The mean rectal D 2cc dose differed significantly from the mean dose calculated at the ICRU reference point (p<0.005); the mean difference was 0.82 Gy (0.48 -1.19 Gy). The mean EQD2 was 68.52 ± 7.24 Gy α/β3 for D 2cc, 61.71 ± 2.77 Gy α/β3 at D ICRU and 69.24 ± 6.02 Gy α/β3 at DMax. The mean ratio of D 2cc rectum to D ICRU rectum was 1.25 and the mean ratio of D 2cc rectum to DMax rectum was 0.98 for all individual fractions. The mean dose to the bladder was 6.00 ± 1.90 Gy for D 2cc and 5.10 ± 2.03 Gy at D ICRU. However, the mean D 2cc dose did not differ significantly from the mean dose calculated at the ICRU reference point (p=0.307); the mean difference was 0.90 Gy (0.49-1.25 Gy). The mean EQD2 was 81.85 ± 13.03 Gy α/β3 for D 2cc and 74.11 ± 19.39 Gy α/β3 at D ICRU. The mean ratio of D 2cc bladder to D ICRU bladder was 1.24. In the majority of applications, the maximum dose point was not the ICRU point. On average, the rectum received 77% and bladder received 92% of the prescribed dose. CONCLUSIONS OARs doses assessed by DVH criteria were higher than ICRU point doses. Our data suggest that the estimated dose to the ICRU bladder point may be a reasonable surrogate for the D 2cc and rectal DMax for D 2cc. However, the dose to the ICRU rectal point does not appear to be a reasonable surrogate for the D 2cc.
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Affiliation(s)
- Natasha Hashim
- Faculty of Medicine, University of Technology MARA, Kuala Lumpur, Malaysia E-mail :
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Hymel R, Jones GC, Simone CB. Whole pelvic intensity-modulated radiotherapy for gynecological malignancies: A review of the literature. Crit Rev Oncol Hematol 2015; 94:371-9. [PMID: 25600840 DOI: 10.1016/j.critrevonc.2014.12.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 12/10/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022] Open
Abstract
Radiation therapy has long played a major role in the treatment of gynecological malignancies. There is increasing interest in the utility of intensity-modulated radiotherapy (IMRT) and its application to treat gynecological malignancies. Herein, we review the state-of-the-art use of IMRT for gynecological malignancies and report how it is being used alone as well as in combination with chemotherapy in both the adjuvant and definitive settings. Based on dosimetric and clinical evidence, IMRT can reduce gastrointestinal, genitourinary, and hematological toxicities compared with 3D-conformal radiotherapy for gynecologic malignancies. We discuss how these attributes of IMRT may lead to improvements in disease outcomes by allowing for dose escalation of radiation therapy, intensification of chemotherapy, and limiting toxicity-related treatment breaks. Currently accruing trials investigating pelvic IMRT for cervical and endometrial cancers are discussed.
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Affiliation(s)
- Rockne Hymel
- Louisiana State University Health Sciences Center, School of Medicine, 1901 Perdido Street, New Orleans, LA 70112, United States.
| | - Guy C Jones
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, United States.
| | - Charles B Simone
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States.
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Chen Z, Zhu L, Zhang B, Meng M, Yuan Z, Wang P. Dose-volume histogram predictors of chronic gastrointestinal complications after radical hysterectomy and postoperative intensity modulated radiotherapy for early-stage cervical cancer. BMC Cancer 2014; 14:789. [PMID: 25354964 PMCID: PMC4226909 DOI: 10.1186/1471-2407-14-789] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 10/17/2014] [Indexed: 11/28/2022] Open
Abstract
Background The small bowel is one of the critical organs involved in gastrointestinal complications in cervical cancer treated with postoperative intensity modulated radiotherapy. Even with modest doses of radiation therapy (45-50Gy), the risk of severe injury from postoperative radiation therapy is between 5% and 15%. Up to now, a predictive model of acute GI complications of the small bowel has been established with the aid of Quantitative Analyses of Normal Tissue Effects in the Clinic. However, the correlation between dose-volume effect and chronic GI complications of the small bowel has not been extensively investigated. In the article, the correlation has been studied preliminarily. Methods This study analyzed 84 patients who underwent postoperative IMRT. The organ at risk that was contoured was the small bowel loops. DVH parameters subjected to analysis included maximum and mean dose, the volume of these organs receiving more than 30, 40, and 50 Gy (V30-50 volume) and the volume of V30-50 to total volume (V30-50 ratio). Association between DVH parameters or clinical factors and the incidence of grade 1–2 chronic GI complications were evaluated. Results Body position and RT total dose are significantly associated with grade 1–2 chronic GI complications after postoperative IMRT in early-stage cervical cancer patients. Maximum dose and V40 ratio of the small bowel loops were significantly associated with chronic GI complications (P < 0.05). The optimal threshold were 5586 cGy (maximum dose) and 28% (V40 ratio) of the small bowel loops. Conclusions Maximum dose and V40 ratio of the small bowel loops should be considered synthetically before postoperative IMRT for early-stage cervical cancer.
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Affiliation(s)
| | | | | | | | | | - Ping Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
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Forsyth E, Gioia KT, Lucioni A. Long-Term Complications of the Irradiated Bladder: a Review. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0264-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mazeron R, Kamsu Kom L, Rivin del Campo E, Dumas I, Farha G, Champoudry J, Chargari C, Martinetti F, Lefkopoulos D, Haie-Meder C. Comparison between the ICRU rectal point and modern volumetric parameters in brachytherapy for locally advanced cervical cancer. Cancer Radiother 2014; 18:177-82. [DOI: 10.1016/j.canrad.2014.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 03/03/2014] [Accepted: 03/19/2014] [Indexed: 11/25/2022]
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