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Zhu J, Li X, Huang M, Zhu H, Tan Y, He X, Sun Z, Cheng H, Li F, Jiang P, Lou H, Ke G, Cao X, Zhu L, Xie P, Yan J, Zhang F. Application of Recombinant Human Superoxide Dismutase in Radical Concurrent Chemoradiotherapy for Cervical Cancer to Prevent and Treat Radiation-induced Acute Rectal Injury: A Multicenter, Randomized, Open-label, Prospective Trial. Int J Radiat Oncol Biol Phys 2024; 120:720-729. [PMID: 38705489 DOI: 10.1016/j.ijrobp.2024.04.070] [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: 12/13/2023] [Revised: 03/25/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the efficacy of recombinant human superoxide dismutase (rhSOD) enemas in radiation-induced acute rectal injury (RARI) in patients with locally advanced cervical cancer. METHODS AND MATERIALS In this phase 3, randomized, open-label trial (NCT04819685) conducted across 14 medical centers in China from June 2021 to August 2023, all patients received concurrent chemoradiation therapy (CCRT). The experimental group was treated with a rhSOD enema during chemoradiation therapy, and the control group had no enema. The Common Terminology Criteria for Adverse Events (version 5.0) was used to evaluate radiation therapy-induced side effects. Endoscopic appearance was assessed using the Vienna Rectoscopy Score. The primary endpoint in the acute phase was the occurrence rate and duration of grade ≥1 (≥G1) diarrhea during CCRT. Secondary endpoints included the occurrence rate and duration of ≥G2 and ≥G3 diarrhea, ≥G1 and ≥G2 diarrhea lasting at least 3 days, and damage to the rectal mucosa due to radiation therapy measured by endoscopy. RESULTS Two hundred and eighty-three patients were randomly divided into the experimental (n = 141) or control group (n = 142). The mean number of ≥G1 and ≥G2 diarrhea days were significantly lower in the experimental group than in the control group (3.5 and 0.8 days vs 14.8 and 4.5 days, respectively; P < .001). The incidence of ≥G2 diarrhea decreased from 53.6% to 24.1% when rhSOD enemas were used. Use of antidiarrheals was lower in the experimental group (36.2% vs 55.7%, P < .001). Three patients felt intolerable or abdominal pain after rhSOD enema. RARI grades in the experimental group tended to be lower than those in the control group (P = .061). Logistic regression analysis revealed that rhSOD enema was associated with a lower occurrence rate of ≥G1/2 diarrhea for at least 3 days (P < .001). CONCLUSIONS The results of this study suggest that rhSOD enema is safe and significantly reduces the incidence, severity, and duration of RARI, protecting the rectal mucosa.
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Affiliation(s)
- Jiawei Zhu
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaofan Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Manni Huang
- Department of Gynecological Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong Zhu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan Tan
- Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Xia He
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Zhihua Sun
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Huijun Cheng
- Department of Gynecologic Oncology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Fenghu Li
- Department of Oncology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Hanmei Lou
- Department of Gynecological Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Guihao Ke
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xinping Cao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lihong Zhu
- Radiotherapy Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Peng Xie
- Department of Gynecologic Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Junfang Yan
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Fuquan Zhang
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Wang Y, Zhen H, Hu K, Yu L, Zhang J, Luo C, Yu L, Yan J, Zhang F. A phase I clinical trial evaluating the application of hydrogel in reducing rectal dose during cervical cancer brachytherapy. Clin Transl Radiat Oncol 2024; 49:100867. [PMID: 39386060 PMCID: PMC11462166 DOI: 10.1016/j.ctro.2024.100867] [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: 06/10/2024] [Revised: 08/09/2024] [Accepted: 09/20/2024] [Indexed: 10/12/2024] Open
Abstract
Purpose This study represents a prospective phase I clinical research to verify the effectiveness and reliability of hydrogel application in Chinese cervical cancer patients. Materials and Methods Eight patients were enrolled in the study. After completing intensity-modulated radiotherapy at 50.4 Gy/28 fractions, a 10 mL injection of hydrogel was administered to each patient through the posterior vaginal fornix under CT-guidance. Image-guided brachytherapy under CT or MRI guidance was given with a target dose of 6 Gy in 5 fractions to the high-risk clinical target volume. Rectal, sigmoid colon, and bladder D2cm3 were recorded for each brachytherapy. MRI scans were performed to measure the distance between the rectum and the cervix or tumor, as well as the spacer gel volume. Patients' QLQ-C30 and QLQ-CX24 scores were recorded to assess treatment outcomes, and all adverse events were documented. Results Among the eight patients, the average D2cc was 60.9 ± 3.4 Gy for the rectum, 64.7 ± 6.8 Gy for sigmoid colon and 77.1 ± 7.4 Gy for bladder, respectively. The distance between the cervix and rectum significantly increased after gel injection. None of the eight patients experienced grade 3 or higher acute toxic reactions during brachytherapy. None patient experienced late rectal toxicity. No adverse events definitively associated with the hydrogel were observed. Patients' subjective quality of life scores did not significantly change before and after gel injection. The reduction ro the volume of the hydrogel were observed during the 24 to 36 weeks after injection. Conclusion The application of the hydrogel effectively increased the distance between the cervix and rectum in brachytherapy for cervical cancer, limiting the rectal dose without increasing doses to other critical organs. In the short term, no severe adverse events were observed, indicating the safety and reliability of this approach. Further research is warranted to confirm its long-term safety and effectiveness.
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Affiliation(s)
- Yuxuan Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongnan Zhen
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jie Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chunli Luo
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lihua Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Gao H, Wu H, Zhang Y, Li X, Qi Z, Wang M, Wang S. Long-term survival in patients with para-aortic metastatic cervical cancer receiving simultaneous integrated boost chemoradiation to positive lymph nodes: a single-center experience. Int J Gynecol Cancer 2024; 34:1536-1546. [PMID: 39209431 DOI: 10.1136/ijgc-2024-005664] [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] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVES To examine the benefits of extended-field chemoradiation with simultaneous integrated boost to positive lymph nodes, followed by image-guided adaptive brachytherapy in patients with cervical cancer with para-aortic metastasis. METHODS This retrospective cohort study enrolled 143 patients diagnosed between January 2011 and July 2023 at a single center. Survival and recurrence were evaluated using the Kaplan-Meier method and log-rank test. Cox regression was employed to identify prognostic factors and adjust for confounding factors. Patients were then stratified according to neoadjuvant chemotherapy, and its impact on survival outcomes was evaluated. RESULTS A total of 129 patients completed the entire treatment course. The 5-year overall survival rate was 57.6%, and the para-aortic failure rate was 6.8% after a median follow-up of 61 months (95% CI 49 to 82 months). Multivariate analysis indicated that neoadjuvant chemotherapy, larger primary tumor or pelvic/para-aortic lymph nodes, and lower hemoglobin nadir (for widespread metastasis-free survival only) predicted poorer survival. After propensity score matching, the 5-year para-aortic recurrence-free, widespread metastasis-free, and overall survival rates were 92.2% vs 92.8% (p=0.85), 50.8% vs 72.1% (p=0.007), and 47.5% vs 65.5% (p=0.037), respectively, in groups receiving neoadjuvant chemotherapy or not. Sixteen patients (12.4%) experienced grade 3-4 late toxicities. Patients who received neoadjuvant chemotherapy had a significantly higher incidence of grade 3-4 anemia and neutropenia than those who did not (45.2% vs 26.7% and 38.1% vs 21.8%, respectively), if including another 14 patients who discontinued treatment due to acute vomiting. CONCLUSION Chemoradiation with simultaneous integrated boost to positive lymph nodes demonstrates favorable outcomes and acceptable late toxicities in para-aortic metastatic cervical cancer. Neoadjuvant chemotherapy has been shown to adversely affect outcomes, and acute vomiting is a major cause of treatment abortion.
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Affiliation(s)
- Hui Gao
- Department of Oncology, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Haijing Wu
- Department of Gynecological Oncology, Sichuan Cancer Hospital & Institute, Cancer Hospital Affiliated to School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yue Zhang
- Department of Oncology, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Xiaokai Li
- Department of Oncology, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Zhongchun Qi
- Department of Oncology, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Mingyi Wang
- Department of Obstetrics & Gynecology, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shuai Wang
- Outpatient Department, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
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Lorusso D, Xiang Y, Hasegawa K, Scambia G, Leiva M, Ramos-Elias P, Acevedo A, Cvek J, Randall L, Pereira de Santana Gomes AJ, Contreras Mejía F, Helpman L, Akıllı H, Lee JY, Saevets V, Zagouri F, Gilbert L, Sehouli J, Tharavichitkul E, Lindemann K, Colombo N, Chang CL, Bednarikova M, Zhu H, Oaknin A, Christiaens M, Petru E, Usami T, Liu P, Yamada K, Toker S, Keefe SM, Pignata S, Duska LR. Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18): overall survival results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2024; 404:1321-1332. [PMID: 39288779 DOI: 10.1016/s0140-6736(24)01808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 08/22/2024] [Accepted: 08/27/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND At the first interim analysis of the phase 3 ENGOT-cx11/GOG-3047/KEYNOTE-A18 study, the addition of pembrolizumab to chemoradiotherapy provided a statistically significant and clinically meaningful improvement in progression-free survival in patients with locally advanced cervical cancer. We report the overall survival results from the second interim analysis of this study. METHODS Eligible patients with newly diagnosed, high-risk (FIGO 2014 stage IB2-IIB with node-positive disease or stage III-IVA regardless of nodal status), locally advanced, histologically confirmed, squamous cell carcinoma, adenocarcinoma, or adenosquamous cervical cancer were randomly assigned 1:1 to receive five cycles of pembrolizumab (200 mg) or placebo every 3 weeks with concurrent chemoradiotherapy, followed by 15 cycles of pembrolizumab (400 mg) or placebo every 6 weeks. Pembrolizumab or placebo and cisplatin were administered intravenously. Patients were stratified at randomisation by planned external beam radiotherapy type (intensity-modulated radiotherapy [IMRT] or volumetric-modulated arc therapy [VMAT] vs non-IMRT or non-VMAT), cervical cancer stage at screening (FIGO 2014 stage IB2-IIB node positive vs III-IVA), and planned total radiotherapy (external beam radiotherapy plus brachytherapy) dose (<70 Gy vs ≥70 Gy [equivalent dose of 2 Gy]). Primary endpoints were progression-free survival per RECIST 1.1 by investigator or by histopathological confirmation of suspected disease progression and overall survival defined as the time from randomisation to death due to any cause. Safety was a secondary endpoint. FINDINGS Between June 9, 2020, and Dec 15, 2022, 1060 patients at 176 sites in 30 countries across Asia, Australia, Europe, North America, and South America were randomly assigned to treatment, with 529 patients in the pembrolizumab-chemoradiotherapy group and 531 patients in the placebo-chemoradiotherapy group. At the protocol-specified second interim analysis (data cutoff Jan 8, 2024), median follow-up was 29·9 months (IQR 23·3-34·3). Median overall survival was not reached in either group; 36-month overall survival was 82·6% (95% CI 78·4-86·1) in the pembrolizumab-chemoradiotherapy group and 74·8% (70·1-78·8) in the placebo-chemoradiotherapy group. The hazard ratio for death was 0·67 (95% CI 0·50-0·90; p=0·0040), meeting the protocol-specified primary objective. 413 (78%) of 528 patients in the pembrolizumab-chemoradiotherapy group and 371 (70%) of 530 in the placebo-chemoradiotherapy group had a grade 3 or higher adverse event, with anaemia, white blood cell count decreased, and neutrophil count decreased being the most common adverse events. Potentially immune-mediated adverse events occurred in 206 (39%) of 528 patients in the pembrolizumab-chemoradiotherapy group and 90 (17%) of 530 patients in the placebo-chemoradiotherapy group. This study is registered with ClinicalTrials.gov, NCT04221945. INTERPRETATION Pembrolizumab plus chemoradiotherapy significantly improved overall survival in patients with locally advanced cervical cancer These data, together with results from the first interim analysis, support this immuno-chemoradiotherapy strategy as a new standard of care for this population. FUNDING Merck Sharp & Dohme, a subsidiary of Merck & Co.
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MESH Headings
- Adult
- Aged
- Female
- Humans
- Middle Aged
- Adenocarcinoma/drug therapy
- Adenocarcinoma/mortality
- Adenocarcinoma/radiotherapy
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma, Adenosquamous/drug therapy
- Carcinoma, Adenosquamous/mortality
- Carcinoma, Adenosquamous/radiotherapy
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/radiotherapy
- Chemoradiotherapy/methods
- Double-Blind Method
- Neoplasm Staging
- Progression-Free Survival
- Uterine Cervical Neoplasms/drug therapy
- Uterine Cervical Neoplasms/mortality
- Uterine Cervical Neoplasms/radiotherapy
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Affiliation(s)
- Domenica Lorusso
- Gynaecology Oncology Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Gynaecology Oncology Unit, Humanitas San Pio X, Milan, Italy.
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Kosei Hasegawa
- Department of Obstetrics and Gynecology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Giovanni Scambia
- Scientific Directorate, Fondazione Policlinico Universitario Agostino Gemelli IRCCS and Catholic University of the Sacred Heart, Rome, Italy
| | - Manuel Leiva
- Oncología Médica, Instituto Peruano de Oncología y Radioterapia, Lima, Perú
| | - Pier Ramos-Elias
- Oncología Médica, Integra Cancer Institute, Edificio Integra Medical Center, Guatemala City, Guatemala
| | | | - Jakub Cvek
- Department of Oncology, University of Ostrava, North Moravia, Czech Republic
| | - Leslie Randall
- Gynecologic Oncology, Virginia Commonwealth University, Massey Comprehensive Cancer Center, Richmond, VA, USA
| | | | | | - Limor Helpman
- Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel
| | - Hüseyin Akıllı
- Turkish Society of Gynecologic Oncology, Başkent University, Ankara, Turkiye
| | - Jung-Yun Lee
- Yonsei Cancer Center and Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Valeriya Saevets
- Gynaecological Oncology, Chelyabinsk Regional Clinical Center for Oncology and Nuclear Medicine, Chelyabinsk, Russia
| | - Flora Zagouri
- Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - Lucy Gilbert
- Division of Gynecologic Oncology, McGill University Health Centre, Research Institute-McGill University Health Centre, Gerald Bronfman Department of Oncology McGill University, Montreal, QC, Canada
| | - Jalid Sehouli
- Department of Gynecology, Charite Universitaetsmedizin, Berlin, Germany; North-Eastern German Society of Gynecological Oncology, Berlin, Germany
| | - Ekkasit Tharavichitkul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital and the Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Nordic Society of Gynaecological Oncology Clinical Trial Unit, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nicoletta Colombo
- Department of Obstetrics and Gynecology, University of Milan-Bicocca and European Institute of Oncology IRCCS, -Milan, Italy
| | - Chih-Long Chang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Marketa Bednarikova
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Hong Zhu
- Department of Oncology, Xiangya Hospital, Central South University, Hunan, China
| | - Ana Oaknin
- Medical Oncology Service, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Melissa Christiaens
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Edgar Petru
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria; AGO-Austria, Innsbruck, Austria
| | - Tomoka Usami
- Department of Obstetrics and Gynecology, Ehime University Hospital, Toon, Ehime, Japan
| | | | | | | | | | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy
| | - Linda R Duska
- Gynelogic Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Georgi PD, Nielsen SK, Hansen AT, Spejlborg H, Rylander S, Lindegaard J, Buus S, Wulff C, Petric P, Tanderup K, Johansen JG. In vivo dosimetry with an inorganic scintillation detector during multi-channel vaginal cylinder pulsed dose-rate brachytherapy: Dosimetry for pulsed dose-rate brachytherapy. Phys Imaging Radiat Oncol 2024; 32:100638. [PMID: 39310220 PMCID: PMC11413746 DOI: 10.1016/j.phro.2024.100638] [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: 01/31/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 09/25/2024] Open
Abstract
Background and purpose In vivo dosimetry is not standard in brachytherapy and some errors go undetected. The aim of this study was to evaluate the accuracy of multi-channel vaginal cylinder pulsed dose-rate brachytherapy using in vivo dosimetry. Materials and methods In vivo dosimetry data was collected during the years 2019-2022 for 22 patients (32 fractions) receiving multi-channel cylinder pulsed dose-rate brachytherapy. An inorganic scintillation detector was inserted in a cylinder channel. Each fraction was analysed as independent data sets. In vivo dosimetry-based source-tracking was used to determine the relative source-to-detector position. Measured dose was compared to planned and re-calculated source-tracking based doses. Assuming no change in organ and applicator geometry throughout treatment, the planned and source-tracking based dose distributions were compared in select volumes via γ-index analysis and dose-volume-histograms. Results The mean ± SD planned vs. measured dose deviations in the first pulse were 0.8 ± 5.9 %. In 31/32 fractions the deviation was within the combined in vivo dosimetry uncertainty (averaging 9.7 %, k = 2) and planning dose calculation uncertainty (1.6 %, k = 2). The dwell-position offsets were < 2 mm for 88 % of channels, with the largest being 5.1 mm (4.0 mm uncertainty, k = 2). 3 %/2 mm γ pass-rates averaged 97.0 % (clinical target volume (CTV)), 100.0 % (rectum), 99.9 % (bladder). The mean ± SD deviation was -1. 1 ± 2.9 % for CTV D98, and -0.2 ± 0.9 % and -1.2 ± 2.5 %, for bladder and rectum D2cm3 respectively, indicating good agreement between intended and delivered dose. Conclusions In vivo dosimetry verified accurate and stable dose delivery in multi-channel vaginal cylinder based pulsed dose-rate brachytherapy.
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Affiliation(s)
- Peter D. Georgi
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren K. Nielsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Anders T. Hansen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Harald Spejlborg
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Susanne Rylander
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Lindegaard
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Buus
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Wulff
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Primoz Petric
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob G. Johansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Marsilla J, Weiss J, Ye XY, Welch M, Milosevic M, Lyng H, Hompland T, Bruheim K, Tadic T, Haibe-Kains B, Han K. A T2-weighted MRI-based radiomic signature for disease-free survival in locally advanced cervical cancer following chemoradiation: An international, multicentre study. Radiother Oncol 2024; 199:110463. [PMID: 39067707 DOI: 10.1016/j.radonc.2024.110463] [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: 04/09/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION To develop and validate a T2-weighted magnetic resonance imaging (MRI)-based radiomic signature associated with disease-free survival (DFS) in locally advanced cervical cancer. MATERIALS AND METHODS The study comprised a training dataset of 132 patients (93 Norwegian; 39 The Cancer Imaging Archive (TCIA) and an independent validation Canadian dataset of 199 patients with FIGO stage IB-IVA cervical cancer treated with chemoradiation. Radiomic features were extracted using PyRadiomics. A radiomic signature was developed based on a multivariable radiomic prognostic model for DFS built using the training dataset, with minimal redundancy maximum relevancy feature selection method. Univariate and multivariable Cox regression analyses were then conducted to examine the association of the derived radiomic signature with DFS. RESULTS A radiomic signature was prognostic for DFS in the training cohort (Norwegian hazard ratio [HR] 5.54, p = 0.002; TCIA HR 3.59, p = 0.04). The radiomic signature remained independently associated with DFS (HR 3.70, p = 0.004) when adjusted for stage and tumor volume. The radiomic signature was also prognostic for DFS in the validation cohort, both on univariate analysis (HR 2.22, p = 0.003), and multivariable analysis adjusted for stage and tumor volume (HR 1.84, p = 0.04). The 4-year DFS rates of patients with radiomic signature score > 0 vs ≤ 0 were 48.2 % vs 87.9 %, and 56.4 % vs 80.8 % for training and validation cohorts respectively. CONCLUSION An MRI-based radiomic signature can be used as a prognostic biomarker for DFS in patients with locally advanced cervical cancer undergoing chemoradiation.
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Affiliation(s)
- Joseph Marsilla
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Jessica Weiss
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Xiang Y Ye
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Mattea Welch
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Cancer Digital Intelligence Program, University Health Network, Toronto, Ontario, Canada
| | - Michael Milosevic
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Heidi Lyng
- Department of Radiation Biology, Oslo University Hospital, Oslo, Norway
| | - Tord Hompland
- Department of Physics, University of Oslo, Oslo, Norway
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Haibe-Kains
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Cancer Digital Intelligence Program, University Health Network, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
| | - Kathy Han
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Jindakan S, Tharavichitkul E, Watcharawipha A, Nobnop W. Improvement of treatment plan quality with modified fixed field volumetric modulated arc therapy in cervical cancer. J Appl Clin Med Phys 2024; 25:e14479. [PMID: 39032169 PMCID: PMC11466474 DOI: 10.1002/acm2.14479] [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: 04/17/2024] [Revised: 05/23/2024] [Accepted: 07/07/2024] [Indexed: 07/22/2024] Open
Abstract
PURPOSE This study aims to introduce modified fixed field volumetric modulated arc therapy (MF-VMAT) which manually opened the field size by fixing the jaws and comparing it to the typical planning technique, auto field volumetric modulated arc therapy (AF-VMAT) in cervical cancer treatment planning. METHODS AND MATERIALS Previously treated twenty-eight cervical cancer plans were retrospectively randomly selected and replanned in this study using two different planning techniques: AF-VMAT and MF-VMAT, resulting in a total of fifty-six treatment plans. In this study, we compared both planning techniques in three parts: (1) Organ at Risk (OARs) and whole-body dose, (2) Treatment plan efficiency, and (3) Treatment plan accuracy. RESULTS For OARs dose, bowel bag (p-value = 0.001), rectum (p-value = 0.002), and left femoral head (p-value = 0.001) and whole-body (p-value = 0.000) received a statistically significant dose reduction when using the MF-VMAT plan. Regarding plan efficiency, MF-VMAT exhibited a statistically significant increase in both number of monitor units (MUs) and control points (p-values = 0.000), while beam-on time, maximum leaf travel, average maximum leaf travel, and maximum leaf travel per gantry rotation were statistically significant decreased (p-values = 0.000). In terms of plan accuracy, the average gamma passing rate was higher in the MF-VMAT plan for both absolute dose (AD) (p-value = 0.001, 0.004) and relative dose (RD) (p-value = 0.000, 0.000) for 3%/3 and 3%/2 mm gamma criteria, respectively. CONCLUSION The MF-VMAT planning technique significantly reduces OAR doses and decreases the spread of low doses to normal tissues in cervical cancer patients. Additionally, this planning approach demonstrates efficient plans with lower beam-on time and reduced maximum leaf travel. Furthermore, it indicates higher plan accuracy through an increase in the average gamma passing rate compared to the AF-VMAT plan. Consequently, MF-VMAT offers an effective treatment planning technique for cervical cancer patients.
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Affiliation(s)
- Sirawat Jindakan
- Medical Physics ProgramDepartment of RadiologyFaculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Ekkasit Tharavichitkul
- Department of RadiologyFaculty of MedicineThe Division of Radiation OncologyChiang Mai UniversityChiang MaiThailand
| | - Anirut Watcharawipha
- Department of RadiologyFaculty of MedicineThe Division of Radiation OncologyChiang Mai UniversityChiang MaiThailand
| | - Wannapha Nobnop
- Department of RadiologyFaculty of MedicineThe Division of Radiation OncologyChiang Mai UniversityChiang MaiThailand
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8
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Zhang Z, Zhao H, Cheng G. Long term clinical outcomes of cervical cancer patients who were recommended surgery but did not undergo it: A SEER database study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108572. [PMID: 39121635 DOI: 10.1016/j.ejso.2024.108572] [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: 05/30/2024] [Revised: 07/19/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND This study analyzed the long-term clinical outcomes of cervical cancer patients recommended surgery but who did not undergo it using the Surveillance, Epidemiology, and End Results (SEER) database. The aim was to identify the subgroups with comparable overall survival (OS) and cancer-specific survival (CSS) through stratified analysis. METHODS Cases of cervical cancer were retrieved from SEER database using SEER*Stat software. This included patients in the non-surgery group (recommended surgery but did not undergo it), and a reference surgery group. Propensity score matching balanced differences between the non-surgery and surgery groups. Stratified analysis and log-rank tests were used to identify subgroups within the non-surgery group with comparable OS and CSS to the surgery group. RESULTS A total of 30,807 cervical cancer patients were included in the OS and CSS analysis. In the matched cohort (n = 1278), patients in the non-surgery group had significantly lower 5-year CSS (63.2 % vs. 80.1 %, P < 0.001) and 5-year OS (59.0 % vs. 78.0 %, P < 0.001). However, within the matched cohort, there was no statistically significant difference in OS and CSS between the non-surgery and surgery groups in subgroups diagnosed during 2010-2014 (P = 0.064, P = 0.182), 2015-2020 (P = 0.122, P = 0.518), T2 stage (P = 0.139, P = 0.052), T3 stage (P = 0.502, P = 0.317), or with distant metastasis (M1) (P = 0.411, P = 0.520). CONCLUSION Patients in the non-surgery group generally exhibited lower long-term clinical outcomes compared to those in the surgery group. However, with advancements in non-surgical treatment techniques, particularly notable in patients with T2, T3, and M1 stages, these differences are gradually diminishing.
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Affiliation(s)
- Zhaoming Zhang
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun City, Jilin, PR China
| | - Hongfu Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun City, Jilin, PR China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun City, Jilin, PR China.
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9
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Tian M, Xu H, Wang H, Wang H, Dai Z, Ding C, Guo H, Jin X. Pretreatment Computed Tomography-Defined Sarcopenia, Treatment-Associated Muscle Loss, and Survival in Patients With Cervical Cancer: A Systematic Review and Meta-Analysis. Nutr Rev 2024:nuae130. [PMID: 39340837 DOI: 10.1093/nutrit/nuae130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2024] Open
Abstract
CONTEXT Sarcopenia has been identified as a potential predictor of poor prognosis in various types of cancer. However, the impact of pretreatment sarcopenia and the reduction of skeletal muscle mass during treatment on survival outcomes of patients with cervical cancer is still not well understood. OBJECTIVE This meta-analysis was conducted to investigate the impact of pretreatment sarcopenia and treatment-associated muscle loss on survival outcomes in patients with cervical cancer. DATA SOURCES The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for studies exploring the relationship between muscle loss and the prognosis of cervical cancer until January 1, 2023. DATA EXTRACTION The hazard ratios (HRs) and 95% CIs for overall survival (OS) and progression-free survival (PFS) were extracted. DATA ANALYSIS The data were analyzed using R software. The studies' quality was assessed using the Quality in Prognostic Studies tool. Twelve observational studies involving 1498 patients with cervical cancer were included in the analysis, with a prevalence of sarcopenia ranging from 24.8% to 57.5%. Sarcopenia was an independent predictor of poor OS (HR, 1.68; 95% CI, 1.28-2.21; P < .01) and PFS (HR, 1.53; 95% CI, 1.19-1.98; P < .01) in patients with cervical cancer. Additionally, the decrease in skeletal muscle during treatment was also significantly related to the OS (HR, 4.46; 95% CI, 2.87-6.94; P < .01) and PFS (HR, 2.89; 95% CI. 1.83-4.55; P < .01). CONCLUSIONS The prevalence of pretreatment sarcopenia was high among patients with cervical cancer. Pretreatment sarcopenia and skeletal muscle loss during treatment both negatively affected prognosis in cervical cancer.
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Affiliation(s)
- Mengxing Tian
- Department of Clinical Nutrition, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Huiting Xu
- Department of Abdominal Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Hongbin Wang
- Department of Gynecology and Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Huifen Wang
- Nursing Department, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Zhu Dai
- Department of Clinical Nutrition, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Chenchen Ding
- Department of Clinical Nutrition, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Huan Guo
- Department of Clinical Nutrition, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
| | - Xin Jin
- Department of Clinical Nutrition, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430079, China
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10
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Abdel-Wahab M, Giammarile F, Carrara M, Paez D, Hricak H, Ayati N, Li JJ, Mueller M, Aggarwal A, Al-Ibraheem A, Alkhatib S, Atun R, Bello A, Berger D, Delgado Bolton RC, Buatti JM, Burt G, Bjelac OC, Cordero-Mendez L, Dosanjh M, Eichler T, Fidarova E, Gondhowiardjo S, Gospodarowicz M, Grover S, Hande V, Harsdorf-Enderndorf E, Herrmann K, Hofman MS, Holmberg O, Jaffray D, Knoll P, Kunikowska J, Lewis JS, Lievens Y, Mikhail-Lette M, Ostwald D, Palta JR, Peristeris P, Rosa AA, Salem SA, Dos Santos MA, Sathekge MM, Shrivastava SK, Titovich E, Urbain JL, Vanderpuye V, Wahl RL, Yu JS, Zaghloul MS, Zhu H, Scott AM. Radiotherapy and theranostics: a Lancet Oncology Commission. Lancet Oncol 2024:S1470-2045(24)00407-8. [PMID: 39362232 DOI: 10.1016/s1470-2045(24)00407-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 10/05/2024]
Abstract
Following on from the 2015 Lancet Oncology Commission on expanding global access to radiotherapy, Radiotherapy and theranostics: a Lancet Oncology Commission was created to assess the access and availability of radiotherapy to date and to address the important issue of access to the promising field of theranostics at a global level. A marked disparity in the availability of radiotherapy machines between high-income countries and low-income and middle-income countries (LMICs) has been identified previously and remains a major problem. The availability of a suitably trained and credentialled workforce has also been highlighted as a major limiting factor to effective implementation of radiotherapy, particularly in LMICs. We investigated initiatives that could mitigate these issues in radiotherapy, such as extended treatment hours, hypofractionation protocols, and new technologies. The broad implementation of hypofractionation techniques compared with conventional radiotherapy in prostate cancer and breast cancer was projected to provide radiotherapy for an additional 2·2 million patients (0·8 million patients with prostate cancer and 1·4 million patients with breast cancer) with existing resources, highlighting the importance of implementing new technologies in LMICs. A global survey undertaken for this Commission revealed that use of radiopharmaceutical therapy-other than 131I-was highly variable in high-income countries and LMICs, with supply chains, workforces, and regulatory issues affecting access and availability. The capacity for radioisotope production was highlighted as a key issue, and training and credentialling of health professionals involved in theranostics is required to ensure equitable access and availability for patient treatment. New initiatives-such as the International Atomic Energy Agency's Rays of Hope programme-and interest by international development banks in investing in radiotherapy should be supported by health-care systems and governments, and extended to accelerate the momentum generated by recognising global disparities in access to radiotherapy. In this Commission, we propose actions and investments that could enhance access to radiotherapy and theranostics worldwide, particularly in LMICs, to realise health and economic benefits and reduce the burden of cancer by accessing these treatments.
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Affiliation(s)
- May Abdel-Wahab
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria.
| | - Francesco Giammarile
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Mauro Carrara
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Diana Paez
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Hedvig Hricak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Molecular Pharmacology Program, Sloan Kettering Institute, New York, NY, USA; Department of Radiology, Weill Cornell Medical College, New York, NY, USA; Gerstner Sloan Kettering Graduate School of Biomedical Sciences, New York, NY, USA
| | - Nayyereh Ayati
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, VIC, Australia
| | - Jing Jing Li
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, VIC, Australia
| | | | - Ajay Aggarwal
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Akram Al-Ibraheem
- Department of Nuclear Medicine, King Hussein Cancer Center, Amman, Jordan; Division of Nuclear Medicine, Department of Radiology and Nuclear Medicine, University of Jordan, Amman, Jordan
| | - Sondos Alkhatib
- Department of Radiation Oncology, Henry Ford Health, Detroit, MI, USA
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Abubakar Bello
- National Hospital, Abuja and Federal University of Health Sciences, Azare, Nigeria
| | - Daniel Berger
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja, Logroño, Spain; Servicio Cántabro de Salud, Santander, Spain
| | - John M Buatti
- Department of Radiation Oncology, Holden Comprehensive Cancer Center, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Olivera Ciraj Bjelac
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Lisbeth Cordero-Mendez
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Manjit Dosanjh
- University of Oxford, Oxford, UK; European Organization for Nuclear Research, Geneva, Switzerland
| | - Thomas Eichler
- Department of Radiation Oncology, Massey Cancer Center Virginia Commonwealth University, Richmond, VA, USA
| | - Elena Fidarova
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | | | - Mary Gospodarowicz
- Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Varsha Hande
- Department of Global Health, Medicine and Welfare, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Ekaterina Harsdorf-Enderndorf
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg, Essen, Germany; German Cancer Consortium, University Hospital Essen, Essen, Germany
| | - Michael S Hofman
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Ola Holmberg
- Division of Radiation, Transport and Waste Safety, Department of Nuclear Safety and Security, International Atomic Energy Agency, Vienna, Austria
| | - David Jaffray
- Department of Radiation Physics and Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Knoll
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Jolanta Kunikowska
- Nuclear Medicine Department, Medical University of Warsaw, Warsaw, Poland
| | - Jason S Lewis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Molecular Pharmacology Program, Sloan Kettering Institute, New York, NY, USA; Department of Pharmacology, Weill Cornell Medical College, New York, NY, USA
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Miriam Mikhail-Lette
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Dennis Ostwald
- WifOR Institute, Darmstadt, Germany; Steinbeis School of International Business and Entrepreneurship, Herrenberg, Germany
| | - Jatinder R Palta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Arthur A Rosa
- Radiation Oncology, Grupo Oncoclinicas, Salvador, Brazil
| | - Soha Ahmed Salem
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | | | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Steve Biko Academic Hospital, Pretoria, South Africa; Nuclear Medicine Research Infrastructure, Pretoria, South Africa
| | | | - Egor Titovich
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Jean-Luc Urbain
- Department of Radiology, Division of Nuclear Medicine, Branford General Hospital, Ontario, Canada
| | - Verna Vanderpuye
- National Center for Radiotherapy Oncology and Nuclear Medicine Department of the Korlebu Teaching Hospital, Accra, Ghana
| | - Richard L Wahl
- Mallinckrodt Institute of Radiology, Department of Radiology, and Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Jennifer S Yu
- Department of Radiation Oncology and Department of Cancer Biology, Cleveland Clinic, Cleveland, OH USA
| | - Mohamed Saad Zaghloul
- Radiation Oncology Department, National Cancer Institute, Cairo University & Children's Cancer Hospital, Cairo, Egypt
| | - Hongcheng Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Andrew M Scott
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia; School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia.
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11
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Simek IM, Sturdza A, Knoth J, Spannbauer A, Bergler-Klein J, Vögele-Kadletz M, Widder J, Schmid MP. Cardiac metastasis in uterine cervical cancer : A systematic review and case study. Strahlenther Onkol 2024:10.1007/s00066-024-02274-y. [PMID: 39287630 DOI: 10.1007/s00066-024-02274-y] [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: 02/29/2024] [Accepted: 07/16/2024] [Indexed: 09/19/2024]
Abstract
PURPOSE Cardiac metastasis from cervical cancer is rare and only scarcely documented. We aim to present a new case and systematically summarize the available literature. MATERIALS AND METHODS PubMed, Scopus, Web of Science, Central, and ClinicalTrials.gov were systematically searched following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria. Results were screened via title, abstract, and full text. Additionally, the reference lists of all papers chosen for the review were screened. RESULTS Eighty-one papers were identified, describing 86 cases in total. Cardiac metastasis occurred at all stages of cervical cancer and in all age groups. Median time from initial diagnosis to diagnosis of cardiac metastasis was 12 months. Patients mainly complained of dyspnea and chest pain, 60.8% had pathologic ECG (electrocardiographic) findings. The cardiac mass was most frequently detected by transthoracic echography. The most common tumor histology was squamous cell carcinoma. Chemotherapy and surgical interventions were the main treatment modalities. Median survival after diagnosis of cardiac metastasis was 3 months. CONCLUSION This largest review on cardiac metastases from cervical cancer confirmed the heart as a very infrequent site of metastasis. There are < 100 cases described in the literature, with very poor prognosis and undefined clinical management.
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Affiliation(s)
- I-M Simek
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - A Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - J Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - A Spannbauer
- Department of Cardiology, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria
| | - J Bergler-Klein
- Department of Cardiology, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria
| | - M Vögele-Kadletz
- Department of Cardiac Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria
| | - J Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - M P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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12
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Alshamrani A, Aznar M, Hoskin P, Chuter R, Eccles CL. The Current use of Adaptive Strategies for External Beam Radiotherapy in Cervical Cancer: A Systematic Review. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00383-2. [PMID: 39366856 DOI: 10.1016/j.clon.2024.09.005] [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: 11/02/2023] [Revised: 08/20/2024] [Accepted: 09/12/2024] [Indexed: 10/06/2024]
Abstract
AIMS Variability in the target and organs at risk (OARs) in cervical cancer treatment presents challenges for precise radiotherapy. Adaptive radiotherapy (ART) offers the potential to enhance treatment precision and outcomes. However, the increased workload and a lack of consensus on the most suitable ART approach hinder its clinical adoption. This systematic review aims to assess the current use of adaptive strategies for cervical cancer and define the optimal approach. MATERIALS AND METHODS A systematic review of current literature published between January 2012 and May 2023 was conducted. Searches used PubMed/Medline, Cochrane Library, and Web of Science databases, supplemented with the University of Manchester, Google Scholar, and papers retrieved from reference lists. The review assessed workflows, compared dosimetric benefits, and examined resources for each identified strategy. Excluded were abstracts, conference abstracts, reviews, articles unrelated to ART management, proton therapy, brachytherapy, or qualitative studies. A narrative synthesis involved data tabulation, summarizing selected studies detailing workflow for cervical cancer and dosimetric outcomes for targets and OARs. RESULTS Sixteen articles met the inclusion criteria; these were mostly retrospective simulation planning studies, except four studies that had been clinically implemented. We identified five approaches for ART radiotherapy for cervical cancer: reactive and scheduled adaptation, internal target volume (ITV)-based approach using library of plans (LOP), fixed-margin approach using LOP, and real-time adaptation, with each approach reducing irradiated volumes without compromising target coverage compared to the non-ART approach. The LOP-based ITV approach is the most used and clinically assessed. CONCLUSION Identifying the optimal strategy is challenging due to dosimetric assessment limitations. Implementing cervical cancer ART necessitates strategic optimization of clinical benefits and resources through research, including studies to identify the optimal frequency, and prospective evaluations of toxicity.
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Affiliation(s)
- A Alshamrani
- Division of Cancer Sciences, The University of Manchester, Manchester, M13 9PL, UK; Princess Nourah Bint Abdulrahman University, Department of Radiological Sciences, College of Health and Rehabilitation Sciences, P.O. Box 84428, Riyadh 11671, Saudi Arabia.
| | - M Aznar
- Division of Cancer Sciences, The University of Manchester, Manchester, M13 9PL, UK.
| | - P Hoskin
- Division of Cancer Sciences, The University of Manchester, Manchester, M13 9PL, UK; The Christie NHS Foundation Trust, Clinical Oncology, Wilmslow Road, Manchester, M20 4BX, UK; 3 Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK.
| | - R Chuter
- Division of Cancer Sciences, The University of Manchester, Manchester, M13 9PL, UK; The Christie NHS Foundation Trust, Clinical Oncology, Wilmslow Road, Manchester, M20 4BX, UK.
| | - C L Eccles
- Division of Cancer Sciences, The University of Manchester, Manchester, M13 9PL, UK; The Christie NHS Foundation Trust, Clinical Oncology, Wilmslow Road, Manchester, M20 4BX, UK.
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13
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Dizendorf E, Chopra S, Mittal P, Gupta A, Nout R, Sturdza A, Chargari C, Tanderup K, Tharavichitkul E, Tatli H, Jeeva M, Jain J, Panda S, Upreti RR, Ghadi Y, Bhavke A, Kohle S, Bhajbhuje R, Agarwal JP. Gynecological brachytherapy hybrid training: The Tata Memorial Centre and BrachyAcademy experience. Brachytherapy 2024:S1538-4721(24)00115-6. [PMID: 39256104 DOI: 10.1016/j.brachy.2024.07.002] [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: 03/12/2024] [Revised: 06/02/2024] [Accepted: 07/03/2024] [Indexed: 09/12/2024]
Abstract
PURPOSE The lack of training is a significant barrier to practicing brachytherapy (BT). Tata Memorial Centre, alongside international BT experts and BrachyAcademy, developed a hybrid gynecological BT training module. This study outlines the preparation, organization, and execution of the 2022-2023 Mumbai training, evaluates its effectiveness, and highlights areas for improvement. MATERIALS AND METHODS Participants were radiation oncologists (RO) and medical physicists (MP) with experience in gynecological BT aiming to transition to image-guided brachytherapy (IGBT). The training covered cervical, endometrial, vaginal, vulvar, periurethral cancers, and pelvic reirradiation. The hybrid course included online pre and postcourse homework assignments, a live workshop with hands-on training, a 6-month online follow-up, and a 12-month opportunity to share the transition experience. RESULTS The December 2022 Mumbai live workshop spanned 2.5 days, attracting 39 participants from 8 countries (Asia, Africa, Australia/Oceania). Feedback rated the course 9/10, with 78% fully meeting expectations. Forty-four percent suggested extending hands-on training. At the 6-month follow-up, response rates were low (33% RO, 11% MP). Among responding RO, 70% reported practice changes after attending the course, 40% implemented IGBT concepts in clinical practice, and 50% increased confidence in image-guided procedures. Overall, 45% of respondent sites could strengthen their intracavitary/interstitial program, while others faced limitations due to lack of access to advanced BT applicators. CONCLUSION The hybrid gynecological BT training concept was successfully executed. Areas for improvement include extending hands-on training and enhancing participant engagement postcourse. Structured steps beyond training may be needed to improve the utilization of advanced brachytherapy for gynecological cancers.
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Affiliation(s)
- Elena Dizendorf
- Nucletron Operations B.V. (Elekta), Veenendaal, The Netherlands.
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Prachi Mittal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ankita Gupta
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Remi Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Cyrus Chargari
- Department of Radiation Oncology, Pitié Salpêtrière Hospital, Paris, France
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ekkasit Tharavichitkul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Hamza Tatli
- Elekta Instrument AB (Elekta), Istanbul, Turkey
| | - Meenakshi Jeeva
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Jeevanshu Jain
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Subhajit Panda
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ritu Raj Upreti
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Yogesh Ghadi
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Akshay Bhavke
- 3D Printing Lab, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Satish Kohle
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Rajesh Bhajbhuje
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Akyildiz A, Gultekin M, Yigit E, Demir E, Ismayilov R, Ahmed M, Buyukkor M, Yildirim HC, Yildirim N, Ucar G, Algin E, Ozturk AE, Akbas S, Selcukbiricik F, Orman S, Turan N, Yilmaz M, Colak R, Engin EO, Majidova N, Bayoglu IV, Beyaz H, Ates O, Ibıs K, Ergen SA, Yuce Sari S, Tezcan Y, Yildiz F, Arik Z. Efficacy of cumulative cisplatin dose on survival in patients with locally advanced cervical cancer treated with definitive chemoradiotherapy: multicenter study by Turkish Oncology Group. Int J Gynecol Cancer 2024; 34:1359-1365. [PMID: 38950923 DOI: 10.1136/ijgc-2024-005419] [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] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVE To investigate the impact of cumulative cisplatin dose on clinical outcomes in locally advanced cervical cancer patients undergoing definitive chemoradiotherapy. METHODS A retrospective analysis was conducted on 654 patients with stage IB3-IVA disease treated with definitive chemoradiotherapy. Radiotherapy was applied as external beam pelvic with or without para-aortic radiotherapy and brachytherapy. Concomitant chemotherapy was in the form of weekly or 3 weekly cisplatin. Data on demographics, treatment protocols, cumulative cisplatin dose, adverse effects, and survival outcomes were collected. Statistical analyses, including univariate and multivariate Cox regression models, were used to assess factors influencing progression free survival and overall survival. RESULTS The median cumulative cisplatin dose was 210 mg (range 40-320), and ≥200 mg in 503 (76.9%) patients. Median follow-up was 35 months (range 1-150). The 5 year progression free survival and overall survival rates were 66.9% and 77.1%, respectively. Multivariate analysis identified poor performance status, non-squamous cell histology, presence of lymph node metastases, and hemoglobin <10 g/dL before chemoradiotherapy as poor prognostic factors for both progression free survival and overall survival in the whole group. When stage III cases were evaluated separately, the cumulative cisplatin dose <200 mg was found to be a significant poor prognostic factor in overall survival (hazard ratio 1.79, 95% confidence interval 1.1 to 3.0, p=0.031). CONCLUSION Our study showed that a cumulative cisplatin dose >200 mg, particularly in patients with lymph node metastases, significantly improved overall survival. Factors such as anemia, toxicity related challenges, and comorbidities were identified as critical considerations in treatment planning. These findings emphasize the balance between maximizing therapeutic efficacy and managing toxicity, guiding personalized treatment approaches for locally advanced cervical cancer.
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Affiliation(s)
- Arif Akyildiz
- Department of Medical Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Melis Gultekin
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ecem Yigit
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ecem Demir
- Department of Radiation Oncology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Rashad Ismayilov
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Melin Ahmed
- Department of Medical Oncology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Buyukkor
- Department of Medical Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Hasan Cagri Yildirim
- Department of Medical Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nilgun Yildirim
- Department of Medical Oncology, Fırat University Faculty of Medicine, Elazig, Turkey
| | - Gokhan Ucar
- Department of Medical Oncology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Efnan Algin
- Department of Medical Oncology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ahmet Emin Ozturk
- Department of Medical Oncology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Sinem Akbas
- Department of Medical Oncology, Koc University Hospital, Istanbul, Turkey
| | | | - Seval Orman
- Department of Medical Oncology, Kartal Dr. Lufti Kirdar City Hospital, Istanbul, Turkey
| | - Nedim Turan
- Department of Medical Oncology, Kartal Dr. Lufti Kirdar City Hospital, Istanbul, Turkey
| | - Mesut Yilmaz
- Department of Medical Oncology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Rumeysa Colak
- Department of Medical Oncology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Esra Ozen Engin
- Department of Medical Oncology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Nargiz Majidova
- Department of Medical Oncology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Ibrahim Vedat Bayoglu
- Department of Medical Oncology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Havva Beyaz
- Department of Radiation Oncology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ozturk Ates
- Department of Medical Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Kamuran Ibıs
- Department of Radiation Oncology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Sefika Arzu Ergen
- Department of Radiation Oncology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Sezin Yuce Sari
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yilmaz Tezcan
- Department of Radiation Oncology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ferah Yildiz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Zafer Arik
- Department of Medical Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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15
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Nuijens AC, Oei AL, Koster L, Hoebe RA, Franken NAP, Rasch CRN, Stalpers LJA. Genetic markers of late radiation toxicity in the era of image-guided radiotherapy: lower toxicity rates reduce the predictive value of γ-H2AX foci decay ratio in patients undergoing pelvic radiotherapy. Radiat Oncol 2024; 19:116. [PMID: 39223539 PMCID: PMC11370123 DOI: 10.1186/s13014-024-02501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND A predictive assay for late radiation toxicity would allow more personalized treatment planning, reducing the burden of toxicity for the more sensitive minority, and improving the therapeutic index for the majority. In a previous study in prostate cancer patients, the γ-H2AX foci decay ratio (γ-FDR) was the strongest predictor of late radiation toxicity. The current study aimed to validate this finding in a more varied group of patients with pelvic cancer. Additionally, the potential correlation between the γ-FDR and patient-reported outcomes was investigated. METHODS Prostate and gynecological cancer patients with ≥ 24 months of follow-up were included in the current analysis. Toxicity was evaluated by physician (CTCAE version 4) and patient (EORTC questionnaires). γ-FDRs were determined in ex vivo irradiated lymphocytes. Correlation between γ-FDR and toxicity was assessed using both linear and logistic regression analyses. The highest toxicity grade recorded during follow-up was used. The association between global quality of life and γ-FDR was tested by comparing the change in quality of life over time in patients with γ-FDR < or ≥ 3.41, a previously established threshold. RESULTS Eighty-eight patients were included. Physician-assessed and patient-reported cumulative grade ≥ 2 toxicity was 25% and 29%, respectively; which is much lower than in the previous cohort (i.e., 51% CTCAE grade ≥ 2). Patients with toxicity exhibited less favorable dose-volume parameters. In men, these parameters showed significant improvement compared to the previous cohort. The proportion of patients with a low γ-FDR increased with severity of toxicity, but this trend was not statistically significant. In addition, a γ-FDR < 3.41 was not correlated with the development of moderate to severe toxicity. Post-treatment decline in global quality of life was minimal, and similar for patients with γ-FDR < or ≥ 3.41. CONCLUSIONS In the present study, the γ-H2AX foci decay ratio could not be validated as a predictor of late radiation toxicity in patients with pelvic cancer. Improved radiotherapy techniques with smaller irradiated bladder and bowel volumes have probably resulted in less toxicities. Future studies on genetic markers of toxicity should be powered on these lower incidences. We further recommend taking persistency, next to severity, into consideration.
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Affiliation(s)
- Anna C Nuijens
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Arlene L Oei
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - Lisa Koster
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ron A Hoebe
- Department of Medical Biology and Core Facility Cellular Imaging, Van Leeuwenhoek Centre for Advanced Microscopy-Academic Medical Center (LCAM-AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolaas A P Franken
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lukas J A Stalpers
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Yoo GS, Sung SY, Song JH, Kim BH, Kwak YK, Kim KS, Byun HK, Kim YS, Kim YJ. Evidence-based clinical recommendations for hypofractionated radiotherapy: exploring efficacy and safety - Part 3. Genitourinary and gynecological cancers. Radiat Oncol J 2024; 42:171-180. [PMID: 39354820 DOI: 10.3857/roj.2023.01046] [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: 12/25/2023] [Accepted: 02/07/2024] [Indexed: 10/03/2024] Open
Abstract
Hypofractionated radiotherapy (RT) has become a trend in the modern era, as advances in RT techniques, including intensity-modulated RT and image-guided RT, enable the precise and safe delivery of high-dose radiation. Hypofractionated RT offers convenience and can reduce the financial burden on patients by decreasing the number of fractions. Furthermore, hypofractionated RT is potentially more beneficial for tumors with a low α/β ratio compared with conventional fractionation RT. Therefore, hypofractionated RT has been investigated for various primary cancers and has gained status as a standard treatment recommended in the guidelines. In genitourinary (GU) cancer, especially prostate cancer, the efficacy, and safety of various hypofractionated dose schemes have been evaluated in numerous prospective clinical studies, establishing the standard hypofractionated RT regimen. Hypofractionated RT has also been explored for gynecological (GY) cancer, yielding relevant evidence in recent years. In this review, we aimed to summarize the representative evidence and current trends in clinical studies on hypofractionated RT for GU and GY cancers addressing several key questions. In addition, the objective is to offer suggestions for the available dose regimens for hypofractionated RT by reviewing protocols from previous clinical studies.
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Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoo-Kang Kwak
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung Su Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yeon Joo Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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17
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Nagao A, Murakami N, Sakuramachi M, Kashihara T, Takahashi K, Kaneda T, Inaba K, Okuma K, Okamoto H, Nakayama Y, Yonemori K, Igaki H. Role of the gel spacer in safely delivering whole pelvic radiation therapy without central shielding in computed tomography-based image-guided adaptive brachytherapy for uterine cervical cancer patients. Brachytherapy 2024; 23:595-603. [PMID: 38942713 DOI: 10.1016/j.brachy.2024.05.007] [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: 12/13/2023] [Revised: 05/11/2024] [Accepted: 05/22/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND To protect the rectum and bladder from high dose exposure, the Japanese guidelines for managing uterine cervical carcinoma recommend pelvic irradiation with central shielding (CS). Conversely, the European Society for Radiotherapy and Oncology (ESTRO) and the American Brachytherapy Society (ABS) guidelines recommend delivering ≥85 Gy to high-risk clinical target volume D90 (CTVHR D90%). In this study, we investigated whether a gel spacer can enable the safe delivery of the ESTRO/ABS-recommended doses to the target while observing dose constraints for the OARs without using CS in external beam radiation therapy (EBRT). MATERIALS AND METHODS Twenty patients who received definitive radiation therapy without CS and were treated by brachytherapy with a gel spacer between 2017 and 2022 were retrospectively reviewed. The cumulative doses of EBRT and brachytherapy treatment outcomes and incidence of adverse events were also examined. RESULTS The median cumulative CTVHR D90%, rectum D2cm3, and bladder D2cm3 were 86.6 Gy, 62.9 Gy, and 72.0 Gy, respectively. The 2-year local control rate was 95%. There were no CTCAE ≥Grade 3 late gastrointestinal or genitourinary adverse events. CONCLUSIONS The use of gel spacer can enable ESTRO/ABS-recommended dose constraints even without using CS in EBRT, with favorable outcomes and low adverse event rates.
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Affiliation(s)
- Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan; Cancer Medicine, Cooperative Graduate School, The Jikei University Graduate School of Medicine, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Radiation Oncology, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Madoka Sakuramachi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoya Kaneda
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kan Yonemori
- Cancer Medicine, Cooperative Graduate School, The Jikei University Graduate School of Medicine, Tokyo, Japan; Department of Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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18
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Peng X, Liu J. The relationship between household income and prognosis of patients with cervical adenocarcinoma in the United States: A retrospective cohort study based on the SEER database. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108516. [PMID: 38968853 DOI: 10.1016/j.ejso.2024.108516] [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: 04/10/2024] [Revised: 06/12/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To investigate the association between household income and overall survival (OS) of patients with cervical adenocarcinoma. METHODS We conducted a retrospective cohort study involving participants selected from the Surveillance, Epidemiology, and End Results (SEER) database. Data were collected on various variables, including demographic variables such as median household income and clinicopathological characteristics for all participants. Cox regression analysis was utilized to examine the association between household income and OS. Subgroup analysis, sensitivity analysis, and E-value were used to further confirm the association. RESULTS A total of 2217 patients were included in the study. Compared with low-income (<$35,000-$54,999), middle-income (55,000-$69,999) or high-income (≥$70,000) was significantly associated with a higher 5-year OS (70.8 %, 58.7 % vs 50 %) in patients with cervical adenocarcinoma. The HR was 0.49, 95 % CI 0.41-0.58, p < 0.001 and 0.66 (0.55-0.78), p < 0.001 respectively, in the unadjusted model. After adjustment for potential confounders, the results were similar (adjusted HR 0.54 (0.45-0.65), p < 0.001) and 0.79 (0.66-0.94), p = 0.01), respectively. This significant association was also present in the various adjusted models. Subgroup and sensitivity analyses suggested that the relationship remained robust and reliable. The E-value analysis indicated robustness to unmeasured confounding. There was evidence of an interaction between age at diagnosis, race, primary site, tumor grade, T, N, M, or Scope Reg LN Sur, and household income on increasing the 5-year OS of cervical adenocarcinoma. CONCLUSIONS Our study found that middle or high household income was significantly associated with a better 5-year OS compared with low household income in patients with cervical adenocarcinoma.
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Affiliation(s)
- Xiaolian Peng
- Department/Division Name: Obstetrics and Gynecology, Xiegang Branch, Dongguan Municipal People's Hospital, Guang Dong Province, China.
| | - Jie Liu
- Department/Division Name: Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China. http://
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Van Vliet-van den Ende KM, Hoogendoorn-Mulder PG, Schokker RI, Moerland MA, Kroon PS, Roesink JM, Fajardo RD, Van der Leij F, Jürgenliemk-Schulz IM. Adaptive brachytherapy for cervical cancer in combined 1.5 T MR/HDR suite: Impact of repeated imaging. Tech Innov Patient Support Radiat Oncol 2024; 31:100262. [PMID: 39224832 PMCID: PMC11367091 DOI: 10.1016/j.tipsro.2024.100262] [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: 04/25/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction At our department we have a dedicated 1.5 Tesla MRI/HDR brachytherapy suite, which provides the possibility of repeated MRI scanning before, during and after applicator insertion and before and/or after irradiation for patients with advanced cervical cancer. In this study we analysed the effect of this adaptive workflow. We investigated the number of interventions, their impact on organ doses (OAR) and the respective dose differences between total prescribed and total delivered doses. Materials and methods Seventy patients with locally advanced cervical cancer FIGO2009 stages IB-IVA, treated from June 2016 till August 2020, were retrospectively analysed. The standard brachytherapy schedule consisted of two applicator insertions and delivery of three or four HDR fractions.OARs were recontoured on the repeated MRI scans. The D2cm3 dose difference between total prescribed and total delivered dose for bladder, rectum, sigmoid and bowel were calculated. Results In total 153 interventions were performed, 3 replacements of the applicator, 23 adaptations of needle positions, bladder filling was changed 74 times and repeated rectal degassing 53 times. The impact of the rectal interventions was on average -1.2 Gy EQD23. Dose differences between total delivered and total prescribed D2cm3 for bladder, rectum, sigmoid and bowel were -0.6, 0.3, 2.2 and -0.6 Gy EQD23, respectively. Conclusions An MRI scanner integrated into the brachytherapy suite enables multiple interventions based on the scans before treatment planning and dose delivery. This allows for customized treatment according to the changing anatomy of the individual patient and a better estimation of the delivered dose.
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Affiliation(s)
| | | | - Rogier I. Schokker
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marinus A. Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra S. Kroon
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith M. Roesink
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Raquel Dávila Fajardo
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Femke Van der Leij
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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20
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Ka K, Cordoba A, Cagetti LV, Schiappa R, Kissel M, Escande A, Casabianca LG, Buchalet C, Gouy S, Morice P, Narducci F, Martinez C, Jauffret C, Lambaudie E, Delpech Y, Laas E, Gaillard T, Hannoun-Levi JM, Espenel S, Chargari C. Preoperative brachytherapy of early-stage cervical cancer: A multicenter study by the SFRO brachytherapy group. Gynecol Oncol 2024; 188:90-96. [PMID: 38941964 DOI: 10.1016/j.ygyno.2024.06.010] [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: 05/07/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE To report the results of a multicenter cohort of preoperative brachytherapy (PBT) for treatment of early-stage cervical cancer (ESCC). METHODS A retrospective analysis was conducted among five French comprehensive cancer centers on behalf of the SFRO Brachytherapy Group to examine the outcome of patients with ESCC who received PBT between 2001 and 2019 because of adverse prognostic factors (tumor size >2 cm, presence of lymphovascular invasion, adenocarcinoma).Brachytherapy was followed 4-8 weeks later by surgery. Local relapse free, distant metastasis-free survival, disease-free, and overall survival and adverse effects were examined. Uni- and multivariate analyses were conducted looking for oncological prognostic factors. RESULTS A total of 451 patients were identified, with a mean tumor size of 24.7 mm. Adenocarcinoma accounted for 43.5% of cases, and lympho-vascular space invasion (LVSI) was present in 15.7%. A complete histological response was observed in 69.6%. With a mean follow-up of 75.4 months, DFS, LRFS, and OS rates at five years were 88% [95% CI (84-91), 98% [95% CI (96-99), and 92% [95% CI (87-95)], respectively. At the last follow-up, 8.2% of patients had died, including 31 (6.8%) from cervical cancer. Severe side effects range from 1.1% to 2%. At multivariate analysis, adenocarcinoma histological type, tumor size ≥2 cm, and the presence of residual tumors were prognosticators for DFS and DMFS. CONCLUSION PBT shows excellent oncological outcomes in this cohort of patients with adverse histoprognostic factors. Favorable survival rates and low complications rates were observed, supporting this strategy in the management of ESCC.
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Affiliation(s)
- Kanta Ka
- Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif, France
| | - Abel Cordoba
- Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | | | - Renaud Schiappa
- Department of Epidemiology, Biostatistics and Health Data, Centre Antoine Lacassagne, University of Côte d'Azur, Nice, France
| | - Manon Kissel
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Alexandre Escande
- Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | | | - Chloe Buchalet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Sebastien Gouy
- Department of Surgical Oncology, Gustave Roussy Cancer Center, Villejuif, France
| | - Philippe Morice
- Department of Surgical Oncology, Gustave Roussy Cancer Center, Villejuif, France
| | - Fabrice Narducci
- Department of Surgical Oncology, Oscar Lambret Cancer Center, Lille, France
| | - Carlos Martinez
- Department of Surgical Oncology, Oscar Lambret Cancer Center, Lille, France
| | - Camille Jauffret
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Eric Lambaudie
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Yann Delpech
- Department of Breast and Gynaecological Surgery, Centre Antoine Lacassagne, Nice, France
| | - Enora Laas
- Department of Surgical Oncology, Institut Curie, Paris, France
| | - Thomas Gaillard
- Department of Surgical Oncology, Institut Curie, Paris, France
| | | | - Sophie Espenel
- Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif, France
| | - Cyrus Chargari
- Department of Radiation Oncology, Pitié Salpetrière Hospital - APHP Sorbonne University, Paris, France.
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Chuk E, Conway JL, Hanuschak J, Han K, Milosevic M, Lukovic J, Ferguson SE, Salman A, Santiago AT, Rink A, Croke J. Patient-reported sexual health outcomes of cervical cancer patients treated with definitive chemoradiation and MRI-guided brachytherapy. Gynecol Oncol 2024; 190:153-159. [PMID: 39197414 DOI: 10.1016/j.ygyno.2024.08.022] [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: 06/19/2024] [Revised: 08/14/2024] [Accepted: 08/20/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND Sexual health is an important survivorship issue in cervical cancer. We assessed patient-reported sexual health outcomes and correlations with oncologist-assessed vaginal toxicity (VT). METHODS This was a prospective, cross-sectional study of stage IB-IVA cervical cancer patients treated with definitive chemoradiation, who completed a socio-demographic questionnaire and the following patient-reported-outcomes (PROs): Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), Menopause Rating Scale (MRS), Hospital Anxiety and Depression Scale (HADS). VT was assessed using the CTCAE v4.0. Sociodemographic, clinical data, PROs and VT were summarized using descriptive statistics; correlations were evaluated using linear regression analyses. RESULTS Between August 2018 and April 2022, 73 patients were analyzed. Median age was 49 (range 25-81), 57.5% had vaginal involvement at diagnosis and 76.9% were partnered. Sexual dysfunction (FSFI score ≤ 26), sexual distress (FSDS-R ≥ 11), severe menopausal symptoms (MRS ≥ 17), anxiety (HAD-Anxiety >7) and depression (HAS-Depression >7) were reported in 86.3%, 54.5%, 36.2%, 46.6% and 24.7%, respectively. Grade 2+ VT was reported in 27.4%. No significant associations were found between PROs and VT. On multivariable analysis, non-partnered status, use of hormone replacement therapy, and International Commission on Radiation Units and Measurements - rectovaginal dose (ICRU-RV) >65Gy were associated with worse sexual health (p < 0.005). CONCLUSION Cervical cancer patients self-report high rates of sexual distress, dysfunction and menopause symptoms. Discordance between oncologist-assessed VT and PROs highlights the importance of evaluating the patient's experience. Proactive treatment of menopausal symptoms and attention to radiotherapy doses to the vagina should be considered.
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Affiliation(s)
- Elizabeth Chuk
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jessica L Conway
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Simcoe Muskoka Regional Cancer Centre, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Jennifer Hanuschak
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kathy Han
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael Milosevic
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jelena Lukovic
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sarah E Ferguson
- Division of Gynecologic Oncology, University Health Network/Sinai Health System and Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Ailya Salman
- Division of Gynecologic Oncology, University Health Network/Sinai Health System and Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Anna T Santiago
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Alexandra Rink
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Croke
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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22
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Lindegaard JC, Petric P, Tan LT, Hoskin P, Schmid MP, Jürgenliemk-Schulz I, Mahantshetty U, Kirisits C, Pötter R. Are we making progress in curing advanced cervical cancer-again? Int J Gynecol Cancer 2024:ijgc-2024-005572. [PMID: 38986568 DOI: 10.1136/ijgc-2024-005572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024] Open
Abstract
Major improvements in radiotherapy over the past two decades in the definitive treatment of locally advanced cervical cancer have significantly improved loco-regional control and survival, whereas little progress has been made with chemotherapy since the implementation of concomitant cisplatin 25 years ago. However, the randomized study INTERLACE (A phase III multicenter trial of weekly induction chemotherapy followed by standard chemoradiation versus standard chemoradiation alone in patients with locally advanced cervical cancer) of neoadjuvant chemotherapy presented recently, has shown significant improvement in survival with the use of six cycles of weekly carboplatin and paclitaxel. Although INTERLACE is yet to be published, neoadjuvant chemotherapy is already being advocated as the new standard, and studies are being designed with neoadjuvant chemotherapy followed by chemoradiation and brachytherapy as the standard arm. It is noteworthy that INTERLACE was initiated before the improvements in radiotherapy mentioned above were broadly implemented. The survival rate in the standard arm of INTERLACE was therefore inferior to the results obtained with the latest state-of-the-art external beam radiotherapy and image guided adaptive brachytherapy (EMBRACE, Magnetic Resonance Imaging (MRI)-Guided Brachytherapy in Locally Advanced Cervical Cancer). Moreover, patient selection impedes the comparison of INTERLACE with other studies as the patients included in INTERLACE were younger, had better performance status, and had less advanced disease than in other studies. Notably patients with involved para-aortic nodes were excluded. In this review, we discuss neoadjuvant chemotherapy in the frame of the EMBRACE studies and show how the impact of modern radiotherapy and patient selection affects the interpretation of the results of INTERLACE. This has led us to conclude that neoadjuvant chemotherapy is not needed for the majority of patients with cervical cancer treated with definitive modern radiotherapy, and may cause harm. However, it is possible that short course neoadjuvant chemotherapy may benefit a minor subgroup of patients who need to be identified. Comprehensive understanding, including cost utility analyses, are needed to draw conclusions regarding the potential benefit of neoadjuvant chemotherapy in low and middle income countries with limited access to modern radiotherapy.
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Affiliation(s)
| | - Primoz Petric
- Department of Radiation Oncology, University Hospital Zürich, Zürich, Switzerland
| | - Li-Tee Tan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, Middlesex, UK
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ina Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Umesh Mahantshetty
- Radiation Oncology, Homi Bhabha Cancer Hospital and Research Center, Visakhapatnam, India
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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23
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Rai B, Dey T, Ballari N, Singh M, Miryala R, Srinivasa GY, Kataria V, Naseem R, Thakur S, Arun Singh O, Ghoshal S. Three-Dimensional Conformal Radiotherapy Versus Image-Guided Intensity Modulated External Beam Radiotherapy in Locally Advanced Cervical Cancer: A Phase III Randomized Control Study. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00320-0. [PMID: 39209678 DOI: 10.1016/j.clon.2024.08.004] [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: 01/04/2024] [Revised: 08/04/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
AIMS The standard treatment of locally advanced cervical carcinoma is radical chemoradiation followed by brachytherapy which has improved survival. Hence, a major concern is our attempt to reduce the incidence of acute and late toxicities. IMRT has been shown to reduce toxicities. In this study, we have compared 3DCRT with IG-IMRT using patient-specific margins to evaluate tumor control as well as OAR-related toxicities. MATERIALS AND METHODS This was a single institution prospective phase III randomised control study including patients of squamous cell carcinoma of cervix (stage II-IIIB, FIGO 2009) without pelvic lymph node involvement. All patients were simulated using intermediate bladder filling protocol and those in the IG-IMRT arm, underwent additional scans with full and empty bladder to assess the range of internal motion and generate individualised ITV margin. EBRT dose of 46Gy/23#/4.5 weeks was delivered with weekly concurrent cisplatin followed by brachytherapy. All toxicities during EBRT and till 3 months post brachytherapy were considered acute toxicity. Post-treatment, patients were followed up every 2 months for first 2 years and then once every 6 months. Disease-related outcomes were assessed with clinical examination and symptom-directed imaging. RESULTS Two hundred patients were screened for inclusion and of them, 89 patients in 3DCRT and 84 patients in IG-IMRT arms were considered for final analysis. The baseline characteristics were comparable in both arms, majority of patients in both arms having stage II disease. For OARs, all dosimetric parameters were significantly better in the IG-IMRT arm. Acute radiation induced toxicities (dermatitis, genito-urinary and gastrointestinal toxicities) were significantly less in the IG-IMRT arm. The local, pelvic, and distant control were comparable in both arms. CONCLUSION Based on our experience, the use of IG-IMRT with patient-specific ITV margins results in reduction in acute OAR toxicities in patients without compromising on tumor control.
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Affiliation(s)
- B Rai
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - T Dey
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - N Ballari
- Dept of Radiation Oncology, Homi Bhabha Cancer Hospital and Research Centre, Mullanpur, India.
| | - M Singh
- University Hospitals Birmingham, NHS Foundation Trust, India.
| | - R Miryala
- Dept of Radiation Oncology, Homi Bhabha Cancer Hospital and Research Centre, Vishakhapatnam, India.
| | - G Y Srinivasa
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - V Kataria
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - R Naseem
- Torbay and South Devon, NHS Foundation Trust, India.
| | - S Thakur
- Dept of Radiotherapy, Chitwan Medical College, Bharatpur, Nepal.
| | - O Arun Singh
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - S Ghoshal
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
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24
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Dankulchai P, Prasartseree T, Sittiwong W, Chansilpa Y, Apiwarodom N, Petsuksiri J, Thephamongkhol K, Treechairusame T, Jitwatcharakomol T, Setakornnukul J, Teyateeti A, Rongthong W, Thaweerat W, Suntornpong N, Veerasarn V, Tuntapakul P, Chareonsiriwat N, Manopetchkasem S. Clinical Outcome Comparison between CT-Guided Versus all MRI-Guided Scenarios in Brachytherapy for Cervical Cancer: A Single-Institute Experience. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00322-4. [PMID: 39218741 DOI: 10.1016/j.clon.2024.08.003] [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: 02/20/2024] [Revised: 08/02/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Image-guided adaptive brachytherapy (IGABT) is the standard of care for patients with cervical cancer. The objective of this study was to compare the treatment outcomes and adverse effects of computed tomography (CT)-guided and magnetic resonance imaging (MRI)-guided scenarios. MATERIALS AND METHODS Data of patients with cervical cancer treated using external beam radiotherapy followed by IGABT from 2012 to 2016 were retrospectively reviewed. CT-guided IGABT was compared with the three modes of MRI-guided IGABT: pre-brachytherapy (MRI Pre-BT) without applicator insertion for fusion, planning MRI with applicator in-place in at least 1 fraction (MRI ≥1Fx), and MRI in every fraction (MRI EveryFx). Patient characteristics, oncologic outcomes, and late radiation toxicity were analyzed using descriptive, survival, and correlation statistics. RESULTS Overall, 354 patients were evaluated with a median follow-up of 60 months. The 5-year overall survival (OS) rates were 61.5%, 65.2%, 54.4%, and 63.7% with CT-guided, MRI PreBT, MRI ≥1Fx, and MRI EveryFx IGABT, respectively with no significant differences (p = 0.522). The 5-year local control (LC) rates were 92.1%, 87.8%, 80.7%, and 76.5% (p = 0.133), respectively, with a significant difference observed between the CT-guided and MRI ≥1Fx (p = 0.018). The grade 3-4 late gastrointestinal toxicity rates were 6% in the CT-guided, MRI ≥1Fx, and MRI EveryFx, and 8% in MRI PreBT. The grade 3-4 late genitourinary toxicity rates were 4% in the CT-guided, 2% in MRI PreBT, 1% in MRI ≥1Fx, and none in MRI EveryFx. No significant differences were observed in the oncologic and toxicity outcomes among MRI PreBT, MRI ≥1Fx, and MRI EveryFx. CONCLUSIONS CT-guided IGABT yielded an acceptable 5-year OS, LC, and toxicity profile compared with all MRI scenarios and is a potentially feasible option in resource-limited settings.
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Affiliation(s)
- P Dankulchai
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - T Prasartseree
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - W Sittiwong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Y Chansilpa
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Apiwarodom
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - J Petsuksiri
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - K Thephamongkhol
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - T Treechairusame
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - T Jitwatcharakomol
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - J Setakornnukul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - A Teyateeti
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Rongthong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Thaweerat
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Suntornpong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Veerasarn
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Tuntapakul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Chareonsiriwat
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Manopetchkasem
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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25
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Caruso G, Wagar MK, Hsu HC, Hoegl J, Rey Valzacchi GM, Fernandes A, Cucinella G, Sahin Aker S, Jayraj AS, Mauro J, Pareja R, Ramirez PT. Cervical cancer: a new era. Int J Gynecol Cancer 2024:ijgc-2024-005579. [PMID: 39117381 DOI: 10.1136/ijgc-2024-005579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
Cervical cancer is a major global health issue, ranking as the fourth most common cancer in women worldwide. Depending on stage, histology, and patient factors, the standard management of cervical cancer is a combination of treatment approaches, including (fertility- or non-fertility-sparing) surgery, radiotherapy, platinum-based chemotherapy, and novel systemic therapies such as bevacizumab, immune checkpoint inhibitors, and antibody-drug conjugates. While ambitious global initiatives seek to eliminate cervical cancer as a public health problem, the management of cervical cancer continues to evolve with major advances in imaging modalities, surgical approaches, identification of histopathological risk factors, radiotherapy techniques, and biomarker-driven personalized therapies. In particular, the introduction of immune checkpoint inhibitors has dramatically altered the treatment of cervical cancer, leading to significant survival benefits in both locally advanced and metastatic/recurrent settings. As the landscape of cervical cancer therapies continues to evolve, the aim of the present review is to provide a comprehensive discussion of the current state and the latest practice-changing updates in cervical cancer.
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Affiliation(s)
- Giuseppe Caruso
- Division of Gynecologic Oncology, European Institute of Oncology (IEO), IRCCS, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew K Wagar
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Heng-Cheng Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Surgery, National Taiwan University Cancer Center, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jorge Hoegl
- Obstetrics and Gynecology, Division of Gynecological Oncology, Clínica Maternidad Santa Ana, IVSS, Caracas, Venezuela, Bolivarian Republic of
| | | | - Andreina Fernandes
- Laboratorio de Genética Molecular, Instituto de Oncología y Hematología, Caracas, Venezuela, Bolivarian Republic of
| | - Giuseppe Cucinella
- Gynecologic Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Seda Sahin Aker
- Gynecologic Oncology, Kayseri City Education and Research Hospital, Kayseri, Turkey
- Clinical Anatomy, Ankara University, Ankara, Turkey
| | - Aarthi S Jayraj
- South Tees NHS Foundation Trust, James Cook University, Middlesbrough, UK
| | - Jessica Mauro
- Department of Gynecologic Oncology, Ospedale Michele e Pietro Ferrero, Verduno, Italy
| | - Rene Pareja
- Gynecology, Gynecologic Oncology, Clinica ASTORGA, Medellin, and Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
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26
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Silberstein AE, Schiff JP, Beckert R, Zhao X, Laugeman E, Markovina S, Contreras JA. Cone-Beam Computed Tomography (CBCT)-Guided Adaptive Boost Radiotherapy for a Patient With Locally Advanced Cervical Cancer Ineligible for Brachytherapy. Cureus 2024; 16:e66218. [PMID: 39233928 PMCID: PMC11374352 DOI: 10.7759/cureus.66218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 09/06/2024] Open
Abstract
Brachytherapy is a critical component of locally advanced cervical cancer treatment, and patients ineligible for brachytherapy historically have poor outcomes. Delivery of boost with stereotactic body radiation therapy (SBRT) has been studied, though toxicity is a concern. Recent case reports have explored adaptive radiation boost, which can adjust plans for inter-fraction motion using magnetic resonance guidance. Herein, we report the first patient with locally advanced cervical cancer ineligible for brachytherapy who was treated with a cone-beam computed tomography (CBCT)-guided adaptive boost following completion of chemoradiation. A 71-year-old female with locally advanced cervical cancer was treated with chemoradiation and was deemed ineligible for a brachytherapy boost due to tumor size, geometry, and a fistula with a tumor in the bladder. She was prescribed a boost to the primary tumor of 25 Gy in five fractions using CBCT-guided adaptive radiation following the completion of chemoradiation. A simulation was performed using a non-contrast CT fused with a mid-chemoradiation magnetic resonance imaging (MRI) scan to create an initial plan. For each treatment fraction, kilovoltage CBCTs were acquired, contours of organs at risk (OARs) were adjusted to reflect anatomy-of-the-day, and an adapted plan was generated. The initial and adapted plans were compared using dose-volume histogram objectives, and the adapted plan was used if it resolved OAR constraint violations or improved target coverage. The use of the initial treatment plan would have resulted in constraint violations for the rectum, sigmoid, and bladder in all fractions. The adapted plans achieved hard constraints in all fractions for all four critical OARs. The mean total treatment time across all five fractions was 58 minutes. This case demonstrates the feasibility of a CBCT-guided adaptive boost approach and the dosimetric benefits of plan adaptation in this setting. Though larger-scale and longer-term data are needed, CBCT-guided adaptive radiation may present a feasible alternative modality to deliver boost doses for brachytherapy-ineligible patients.
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Affiliation(s)
- Alice E Silberstein
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Joshua P Schiff
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Robbie Beckert
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Xiaodong Zhao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Jessika A Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
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27
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Jo JH, Lee JW, Seol KH. Assessing the Adequacy of Traditional Vertebral Landmarks as Upper Border of Whole Pelvic Radiotherapy Field for Stage IB2-IIB Cervical Cancer. Cancers (Basel) 2024; 16:2743. [PMID: 39123470 PMCID: PMC11311712 DOI: 10.3390/cancers16152743] [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: 07/04/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
This study investigates the impact of insufficient common iliac lymph node (CIN) irradiation on treatment outcomes in patients with stage IB2-IIB cervical cancer receiving concurrent chemoradiotherapy (CCRT). We retrospectively analyzed 68 patients with Federation of Gynecology and Obstetrics stage IB2-IIB, treated with weekly cisplatin-based CCRT from 2008 to 2018. Patients received external-beam whole pelvic radiotherapy (WPRT) and concurrent cisplatin chemotherapy, followed by high-dose-rate brachytherapy. The WPRT upper border was at L4-5 in 61 patients and L3-4 in 7 patients. Thirty-seven patients had the CIN area fully included (full-CIN group), while 31 had partial inclusion (partial-CIN group). Recurrence rates and survival outcomes were analyzed over a median follow-up of 111 months. Patient characteristics and the irradiated dose were comparable. Treatment failure occurred in three patients (8.1%) in the full-CIN group and in six patients (19.4%) in the partial-CIN group, with CIN and para-aortic lymph node recurrence in two and one patients, respectively. The 5-year cumulative recurrence rate was 0% for the full-CIN group and 11.4% for the partial-CIN group (p = 0.04). Cause-specific survival was 100% vs. 87.1% (p = 0.025), and the overall survival was 94.3% vs. 87.1% (p = 0.44). Fully including the CIN area in WPRT is crucial for stage IB2-IIB cervical cancer. Vascular anatomical margins should be considered over vertebral landmarks.
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Affiliation(s)
- Ji Hwan Jo
- Department of Radiation Oncology, Daegu Catholic University Medical Center, Daegu 42472, Republic of Korea; (J.H.J.); (J.W.L.)
| | - Jeong Won Lee
- Department of Radiation Oncology, Daegu Catholic University Medical Center, Daegu 42472, Republic of Korea; (J.H.J.); (J.W.L.)
- Department of Radiation Oncology, Daegu Catholic University School of Medicine, Daegu 42472, Republic of Korea
| | - Ki Ho Seol
- Department of Radiation Oncology, Daegu Catholic University Medical Center, Daegu 42472, Republic of Korea; (J.H.J.); (J.W.L.)
- Department of Radiation Oncology, Daegu Catholic University School of Medicine, Daegu 42472, Republic of Korea
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28
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Noble DJ, Ramaesh R, Brothwell M, Elumalai T, Barrett T, Stillie A, Paterson C, Ajithkumar T. The Evolving Role of Novel Imaging Techniques for Radiotherapy Planning. Clin Oncol (R Coll Radiol) 2024; 36:514-526. [PMID: 38937188 DOI: 10.1016/j.clon.2024.05.018] [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: 03/24/2024] [Revised: 05/20/2024] [Accepted: 05/30/2024] [Indexed: 06/29/2024]
Abstract
The ability to visualise cancer with imaging has been crucial to the evolution of modern radiotherapy (RT) planning and delivery. And as evolving RT technologies deliver increasingly precise treatment, the importance of accurate identification and delineation of disease assumes ever greater significance. However, innovation in imaging technology has matched that seen with RT delivery platforms, and novel imaging techniques are a focus of much research activity. How these imaging modalities may alter and improve the diagnosis and staging of cancer is an important question, but already well served by the literature. What is less clear is how novel imaging techniques may influence and improve practical and technical aspects of RT planning and delivery. In this review, current gold standard approaches to integration of imaging, and potential future applications of bleeding-edge imaging technology into RT planning pathways are explored.
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Affiliation(s)
- D J Noble
- Department of Clinical Oncology, Edinburgh Cancer Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK; Edinburgh Cancer Research Centre, Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, UK.
| | - R Ramaesh
- Department of Radiology, Western General Hospital, Edinburgh, UK
| | - M Brothwell
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - T Elumalai
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - T Barrett
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - A Stillie
- Department of Clinical Oncology, Edinburgh Cancer Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - C Paterson
- Beatson West of Scotland Cancer Centre, Great Western Road, Glasgow G12 0YN, UK
| | - T Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
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29
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Massobrio R, Bianco L, Campigotto B, Attianese D, Maisto E, Pascotto M, Ruo Redda MG, Ferrero A. New Frontiers in Locally Advanced Cervical Cancer Treatment. J Clin Med 2024; 13:4458. [PMID: 39124724 PMCID: PMC11312973 DOI: 10.3390/jcm13154458] [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: 06/14/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Despite the introduction of targeted vaccines and screening protocols, locally advanced cervical cancer represents a median proportion of 37% among all cervical carcinomas. Compared to early stages, it presents significantly lower cure rates, with a 5-year disease-free survival rate of 68% and a 5-year overall survival rate of 74%. According to current guidelines, definitive radiotherapy with concomitant chemotherapy represents the gold standard for locally advanced cervical cancer treatment. However, a significant number of patients relapse and die from metastatic disease. The aim of this narrative review is to examine the recent advancements in treating locally advanced cervical cancer, exploring new frontiers in therapeutic approaches. The PubMed database and clinical trial registries were searched to identify relevant articles published on locally advanced cervical cancer treatment up to March 2024, mainly focusing on papers published in the last decade. Abstracts presented at major international congresses that bring relevant evidence were included. Progress achieved in refining radiotherapy techniques, recent evidence regarding neoadjuvant treatment preceding surgery or concurrent chemoradiotherapy, and key findings concerning adjuvant treatment are thoroughly explored. Furthermore, a comprehensive review of prominent phase II and phase III trials examining the integration of immune checkpoint inhibitors is conducted, analyzing the various contexts in which they are applied. In light of the new evidence that has emerged in recent years and is discussed in this article, the appropriate selection of the most suitable therapeutic approach for each patient remains a complex but crucial issue.
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Affiliation(s)
- Roberta Massobrio
- Academic Division of Gynecology and Obstetrics, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (R.M.); (B.C.); (D.A.); (E.M.); (M.P.)
| | - Lavinia Bianco
- Department of Radiation Oncology, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (L.B.); (M.G.R.R.)
| | - Beatrice Campigotto
- Academic Division of Gynecology and Obstetrics, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (R.M.); (B.C.); (D.A.); (E.M.); (M.P.)
| | - Daniela Attianese
- Academic Division of Gynecology and Obstetrics, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (R.M.); (B.C.); (D.A.); (E.M.); (M.P.)
| | - Elisa Maisto
- Academic Division of Gynecology and Obstetrics, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (R.M.); (B.C.); (D.A.); (E.M.); (M.P.)
| | - Maria Pascotto
- Academic Division of Gynecology and Obstetrics, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (R.M.); (B.C.); (D.A.); (E.M.); (M.P.)
| | - Maria Grazia Ruo Redda
- Department of Radiation Oncology, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (L.B.); (M.G.R.R.)
| | - Annamaria Ferrero
- Academic Division of Gynecology and Obstetrics, University of Turin, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (R.M.); (B.C.); (D.A.); (E.M.); (M.P.)
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy
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30
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Chopra S, Bosse T, Horeweg N, Deodhar K, Menon S, Rafael T, Pai V, Rijstenberg L, van Kemenade F, Kannan S, Mahantshetty U, Segedin B, Huang F, Bruheim K, Perez M, Rai B, Tan LT, Giannakopoulos N, Schmid M, Tanderup K, Pötter R, Nout RA. Biomarker Expression and Clinical Outcomes in International Study of Chemoradiation and Magnetic Resonance Imaging-Based Image-Guided Brachytherapy for Locally Advanced Cervical Cancer: BIOEMBRACE. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03141-9. [PMID: 39067486 DOI: 10.1016/j.ijrobp.2024.07.2316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/01/2024] [Accepted: 07/13/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE BIOEMBRACE was designed to study the impact of biomarkers in addition to clinicopathological factors on disease outcomes in patients treated with chemoradiation and magnetic resonance imaging (MRI)-guided brachytherapy (BT) for locally advanced cervical cancer in the EMBRACE study. METHODS AND MATERIALS Between 2018 and 2021, 8 EMBRACE-I sites contributed tumor tissue for the immunohistochemistry of p16, PD-L1, and L1CAM. These biomarkers and clinicopathological factors (International Federation of Gynecology and Obstetrics 2009 stage, nodal status, histology, and necrosis on MRI) were analyzed to predict poor response at BT (high-risk clinical target volume [HR-CTV] ≥ 40 cc) at BT) and 5-year local control, pelvic control, and disease-free survival. Interaction between p16, PD-L1, radiation therapy dose (HR-CTV D90), and disease outcomes was investigated. Univariable and multivariable analyses were performed. RESULTS Two hundred sixty-four patients were included. The median HR-CTV D90 was 89 Gy (86-95). P-16 positive status, PD-L1 > 1%, and L1CAM ≥ 10% was noted in 86.6%, 20.1%, and 17.8% of patients, respectively. P16 negative status (odds ratio, 2.0; 95% CI, 1.0-5.7; P = .04) and necrosis on MRI (odds ratio, 2.1; 95% CI, 1.1-4.3; P < .02) independently predicted for HR-CTV ≥ 40 cc, as did the International Federation of Gynecology and Obstetrics stage and tumor width >5 cm. PD-L1 > 1% was associated with reduced local (82% vs 94%; P = .02) and pelvic control (79% vs 89%; P = .02). HR-CTV D90 < 85 Gy was associated with inferior 5-year local control in p16-positive patients, especially if PD-L1 was coexpressed. On multivariable analysis, PD-L1 > 1% was the only independent factor for 5-year local control (hazard ratio, 3.3; P = .04) and L1CAM ≥ 50% for pelvic control (hazard ratio, 5.5; 95% CI, 1.3-23.3; P = .02). CONCLUSIONS P16 negative status and tumor necrosis on MRI are independently associated with poor response to chemoradiation, whereas PD-L1 > 1% and L1CAM ≥ 50% have an independent impact on local and pelvic control, suggesting an impact of biomarker expression on outcomes. Further validation is needed.
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Affiliation(s)
- Supriya Chopra
- Department of Radiation Oncology and Medical Physics, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Santosh Menon
- Department of Pathology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Tynisha Rafael
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Venkatesh Pai
- Department of Radiation Oncology and Medical Physics, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Lucia Rijstenberg
- Department of Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Folkert van Kemenade
- Department of Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sadhana Kannan
- Epidemiology and Clinical Trials Unit, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Umesh Mahantshetty
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Barbara Segedin
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Fleur Huang
- Department of Radiation Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Kjersti Bruheim
- Department of Radiation Oncology, Oslo University Hospital, Oslo, Norway
| | - Margarita Perez
- Department of Radiation Oncology, Navarra Investigacion Biomedical, Pampalona, Spain
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Li Tee Tan
- Department of Clinical Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Nadia Giannakopoulos
- Department of Pathology, Cross Cancer Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Maximilian Schmid
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Danish Cancer Particle Therapy, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Richard Pötter
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Radiation Oncology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Rivera A, Barrios DM, Herbach E, Kahn JM, Williams VM, Mehta KJ, Wolfson A, Portelance L, Kamrava M. Analgesia and Anesthesia Practice Patterns for Gynecologic Brachytherapy Procedures and Potential Impact on Women's Procedural Experience: A National Survey. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02973-0. [PMID: 39067485 DOI: 10.1016/j.ijrobp.2024.07.2150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/19/2024] [Accepted: 07/06/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE The purpose of this study was to determine the current U.S. practice patterns of analgesia (AG) and anesthesia (AS) for gynecologic brachytherapy (BT) procedures. METHODS AND MATERIALS A 27-item survey created with expertise from 5 brachytherapists was distributed electronically to 90 U.S. radiation oncology academic programs and publicized on social media and at 2 national meetings from June to October 2023. RESULTS Forty-one responses were received (46%). Fifty-four percent identified as female, 66% as Caucasian, and 85% as non-Hispanic/Latino ethnicity. Forty-nine percent use a BT suite ± computed tomography (CT) simulator alone, 39% the operating room ± BT suite or CT simulator or other location, 10% CT simulation room alone, and 2% clinic examination room. Thirty-four percent use general anesthesia alone (GA) for intracavitary BT (n = 41), 20% conscious sedation (CS) alone, 10% oral analgesia (OA) alone, 9% spinal or epidural AS alone, and 27% combination. Among those performing hybrid BT (n = 25), 40% use GA alone, 16% use CS alone, 12% epidural or spinal AS alone, 4% OA alone, and 28% combination. For template interstitial BT (n = 25), 44% use GA alone, 48% epidural alone or in combination with other AS, and 8% CS alone. Twenty-two percent of respondents provide AG or AS during applicator placement only, whereas 32% provide it during placement, planning, treatment, and removal. The most common reasons for not using CS or GA were the lack of AS resources and clinician preference. Seventy-three percent reported the belief that patients suffer from post-traumatic stress disorder symptoms after BT. However, 68% reported not using techniques to alleviate BT-related emotional distress. CONCLUSIONS Many U.S. brachytherapists report using GA, CS, or epidural AS; however, 10% are using only OA, and 22% offer AG/AS only during applicator placement. Furthermore, a majority of respondents believe post-traumatic stress disorder symptoms can occur after BT, but few offer any intervention. AS resources and clinician preferences should be targeted for the expansion of higher-quality care.
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Affiliation(s)
- Amanda Rivera
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | | | - Emma Herbach
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Jenna M Kahn
- Kaiser NW Permanente, Interstate Radiation Oncology Center, Portland, Oregon
| | | | - Keyur J Mehta
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Aaron Wolfson
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Lorraine Portelance
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
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Tsuchida K, Yoshida D, Shima S, Kusunoki T, Takayama Y, Koge H, Kano K, Takakusagi Y, Mizoguchi N, Kamada T, Kusano Y, Kato H, Katoh H. Preliminary result of combined treatment with scanning carbon-ion radiotherapy and image-guided brachytherapy for locally advanced cervical adenocarcinoma. JOURNAL OF RADIATION RESEARCH 2024; 65:512-522. [PMID: 38842119 PMCID: PMC11262861 DOI: 10.1093/jrr/rrae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/03/2024] [Indexed: 06/07/2024]
Abstract
Although there is growing evidence of the efficacy of carbon-ion radiotherapy (CIRT) for locally advanced cervical adenocarcinoma, reports on combined treatment with CIRT and image-guided brachytherapy (IGBT) are scarce. We retrospectively analyzed patients with International Federation of Gynecology and Obstetrics (2008) stage II-IVA locally advanced cervical adenocarcinoma who received combined scanning CIRT (sCIRT) and IGBT between April 2019 and March 2022. sCIRT consisted of whole-pelvic irradiation with 36 Gy (relative biological effectiveness [RBE]) in 12 fractions and subsequent local boost irradiation with 19.2 Gy (RBE) in 4 fractions. Three sessions of IGBT were administered after completion of sCIRT. Concurrent chemotherapy using weekly cisplatin (40 mg/m2/week) was also administered. Efficacy, toxicity and dose-volume parameters were analyzed. Fifteen patients were included in the analysis. The median follow-up period was 25 months. The 2-year overall survival, progression-free survival and local control rates were 92.3% (95% confidence interval [CI] = 77.8-100%), 52.5% (95% CI = 26.9-78.1%) and 84.8% (95% CI = 65.2-100%), respectively. Neither severe acute toxicity necessitating treatment cessation nor grade 3 or higher late toxicity were observed. The sigmoid D2cm3 of the patient who developed grade 2 late sigmoid hemorrhage was 65.6 Gy, which exceeded the standard deviation and target dose. The combination of sCIRT and IGBT for locally advanced cervical adenocarcinoma showed acceptable efficacy and safety. Further large-scale and long-term studies are warranted to confirm the efficacy and safety of this treatment.
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Affiliation(s)
- Keisuke Tsuchida
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Daisaku Yoshida
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Satoshi Shima
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Terufumi Kusunoki
- Section of Medical Physics and Engineering, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Yoshiki Takayama
- Section of Medical Physics and Engineering, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Hiroaki Koge
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Kio Kano
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Yosuke Takakusagi
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Nobutaka Mizoguchi
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Tadashi Kamada
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Yohsuke Kusano
- Section of Medical Physics and Engineering, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Hisamori Kato
- Department of Gynecology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
| | - Hiroyuki Katoh
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, Kanagawa 241-8515, Japan
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Restaino S, Pellecchia G, Arcieri M, Bogani G, Taliento C, Greco P, Driul L, Chiantera V, Ercoli A, Fanfani F, Fagotti A, Ciavattini A, Scambia G, Vizzielli G. Management for Cervical Cancer Patients: A Comparison of the Guidelines from the International Scientific Societies (ESGO-NCCN-ASCO-AIOM-FIGO-BGCS-SEOM-ESMO-JSGO). Cancers (Basel) 2024; 16:2541. [PMID: 39061181 PMCID: PMC11274772 DOI: 10.3390/cancers16142541] [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: 06/26/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Cervical cancer continues to have a significant incidence, despite global efforts in HPV vaccination campaigns. Managing this condition involves a diverse team of healthcare professionals. Research in this field is undergoing a period of great revolution in multiple areas, and international guidelines will soon have to adapt to new scientific evidence. This could be true mainly in locally advanced stages, and it could also be true for minimal invasive surgery. This paper aims to summarize and compare the most recent recommendations published by international gynecological oncological societies for patients with cervical cancer. From their comparison, common aspects and disagreements emerged, especially in the diagnostic pathway and follow-up strategies. Several issues that remain to be debated in the literature were addressed and compared, highlighting similarities and differences, from the role of the sentinel lymph node in early stages to that of the adjuvant hysterectomy in locally advanced tumors. On the surgical side, for this last subset of patients, currently, a laparotomic approach is recommended. At the same time, the advent of immunotherapy has just opened up new and promising scenarios in systemic treatment for locally advanced cervical cancer, and international guidelines will soon introduce it into their algorithms.
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Affiliation(s)
- Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.P.); (L.D.); (G.V.)
- PhD School in Biomedical Sciences, Gender Medicine, Child and Women Health, University of Sassari, 07100 Sassari, Italy
| | - Giulia Pellecchia
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.P.); (L.D.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Martina Arcieri
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.P.); (L.D.); (G.V.)
| | - Giorgio Bogani
- Gynaecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milano, Italy;
| | - Cristina Taliento
- Department of Medical Sciences, Obstetrics and Gynecology Unit, University of Ferrara, 44121 Ferrara, Italy; (C.T.); (P.G.)
- Department of Development and Regeneration, Woman and Child, KU Leuven, 3000 Leuven, Belgium
| | - Pantaleo Greco
- Department of Medical Sciences, Obstetrics and Gynecology Unit, University of Ferrara, 44121 Ferrara, Italy; (C.T.); (P.G.)
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.P.); (L.D.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
- Unit of Gynecologic Oncology, National Cancer Institute, IRCCS, Fondazione “G. Pascale”, 80131 Naples, Italy
| | - Alfredo Ercoli
- Department of Human Pathology in Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy;
| | - Francesco Fanfani
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (F.F.); (A.F.); (G.S.)
| | - Anna Fagotti
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (F.F.); (A.F.); (G.S.)
| | - Andrea Ciavattini
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60121 Ancona, Italy;
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (F.F.); (A.F.); (G.S.)
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.P.); (L.D.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
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Klopp AH, Enserro D, Powell M, Randall M, Schink JC, Mannel RS, Holman L, Bender D, Kushnir CL, Backes F, Zweizig SL, Waggoner S, Bradley KA, Lawrence LD, Hanjani P, Darus CJ, Small W, Cardenes HR, Feddock JM, Miller DS. Radiation Therapy With or Without Cisplatin for Local Recurrences of Endometrial Cancer: Results From an NRG Oncology/GOG Prospective Randomized Multicenter Clinical Trial. J Clin Oncol 2024; 42:2425-2435. [PMID: 38662968 DOI: 10.1200/jco.23.01279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/30/2023] [Accepted: 02/20/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE Pelvic recurrence is a frequent pattern of relapse for women with endometrial cancer. A randomized trial compared progression-free survival (PFS) after treatment with radiation therapy alone as compared with concurrent chemotherapy. MATERIALS AND METHODS Between February 2008 and August 2020, 165 patients were randomly assigned 1:1 to receive either radiation treatment alone or a combination of chemotherapy and radiation treatment. The primary objective of this study was to determine whether chemoradiation therapy was more effective than radiation therapy alone at improving PFS. RESULTS The majority of patients had low-grade (1 or 2) endometrioid histology (82%) and recurrences confined to the vagina (86%). External beam with either the three-dimensional or intensity modulated radiation treatment technique was followed by a boost delivered with brachytherapy or external beam. Patients randomly assigned to receive chemotherapy were treated with once weekly cisplatin (40 mg/m2). Rates of acute toxicity were higher in patients treated with chemoradiation as compared with radiation treatment alone. Median PFS was longer for patients treated with radiation therapy alone as compared with chemotherapy and radiation (median PFS was not reached for RT v 73 months for chemoradiation, hazard ratio of 1.25 (95% CI, 0.75 to 2.07). At 3 years, 73% of patients treated definitively with radiation and 62% of patients treated with chemoradiation were alive and free of disease progression. CONCLUSION Excellent outcomes can be achieved for women with localized recurrences of endometrial cancer when treated with radiation therapy. The addition of chemotherapy does not improve PFS for patients treated with definitive radiation therapy for recurrent endometrial cancer and increases acute toxicity. Patients with low-grade and vaginal recurrences who constituted the majority of those enrolled are best treated with radiation therapy alone.
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Affiliation(s)
- Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Danielle Enserro
- Clinical Trials Development Division, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Matthew Powell
- Washington University School of Medicine, Obstetrics & Gynecology, St Louis, MO
| | - Marcus Randall
- University of Kentucky, Radiation Oncology, Lexington, KY
| | - Julian C Schink
- Cancer Treatment Centers of America, City of Hope, Gynecologic Oncology, Chicago, IL
| | | | - Laura Holman
- University of Oklahoma Health Sciences, Oklahoma City, OK
| | - David Bender
- University of Iowa Hospitals & Clinics, Iowa City, IA
| | | | - Floor Backes
- The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - Susan L Zweizig
- University of Massachusetts Memorial Health Care, Gynecologic Oncology, Worcester, MA
| | - Steven Waggoner
- Cleveland Clinic Foundation, Medical Oncology, Cleveland, OH
| | - Kristin A Bradley
- University of Wisconsin Hospital and Clinics, Radiation Oncology, Madison, WI
| | | | - Parviz Hanjani
- Abington Memorial Hospital, Gynecologic Oncology, Abington, PA
| | - Christopher J Darus
- Maine Medical Center, Gynecologic Oncology, Scarborough, ME
- Providence Gynecologic Oncology Program and Earle A Chiles Research Institute, Portland, OR
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Cardinal Bernardin Cancer Center, Chicago, IL
| | - Higinia R Cardenes
- New York-Presbyterian Hospital, Weill Cornell Medicine, Clinical Radiation Oncology, New York, NY
| | | | - David S Miller
- University of Texas Southwestern Medical Center, Gynecologic Oncology, Dallas, TX
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Liu SF, Li MJ, Liang B, Sun W, Shao Y, Hu X, Xing D. Breaking the barrier: Nanoparticle-enhanced radiotherapy as the new vanguard in brain tumor treatment. Front Pharmacol 2024; 15:1394816. [PMID: 39021831 PMCID: PMC11252536 DOI: 10.3389/fphar.2024.1394816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
The pursuit of effective treatments for brain tumors has increasingly focused on the promising area of nanoparticle-enhanced radiotherapy (NERT). This review elucidates the context and significance of NERT, with a particular emphasis on its application in brain tumor therapy-a field where traditional treatments often encounter obstacles due to the blood-brain barrier (BBB) and tumor cells' inherent resistance. The aims of this review include synthesizing recent advancements, analyzing action mechanisms, and assessing the clinical potential and challenges associated with nanoparticle (NP) use in radiotherapy enhancement. Preliminary preclinical studies have established a foundation for NERT, demonstrating that nanoparticles (NPs) can serve as radiosensitizers, thereby intensifying radiotherapy's efficacy. Investigations into various NP types, such as metallic, magnetic, and polymeric, have each unveiled distinct interactions with ionizing radiation, leading to an augmented destruction of tumor cells. These interactions, encompassing physical dose enhancement and biological and chemical radio sensitization, are crucial to the NERT strategy. Although clinical studies are in their early phases, initial trials have shown promising results in terms of tumor response rates and survival, albeit with mindful consideration of toxicity profiles. This review examines pivotal studies affirming NERT's efficacy and safety. NPs have the potential to revolutionize radiotherapy by overcoming challenges in targeted delivery, reducing off-target effects, and harmonizing with other modalities. Future directions include refining NP formulations, personalizing therapies, and navigating regulatory pathways. NERT holds promise to transform brain tumor treatment and provide hope for patients.
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Affiliation(s)
- Shi feng Liu
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Jiao Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
- Qingdao Cancer Institute, Qingdao University, Qingdao, China
| | - Bing Liang
- The Affiliated Hospital of Qingdao University, Qingdao, China
- Qingdao Cancer Institute, Qingdao University, Qingdao, China
| | - Wenshe Sun
- The Affiliated Hospital of Qingdao University, Qingdao, China
- Qingdao Cancer Institute, Qingdao University, Qingdao, China
| | - Yingchun Shao
- Qingdao Cancer Institute, Qingdao University, Qingdao, China
| | - Xiaokun Hu
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dongming Xing
- The Affiliated Hospital of Qingdao University, Qingdao, China
- Qingdao Cancer Institute, Qingdao University, Qingdao, China
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Chargari C, Maury P, Texier M, Genestie C, Morice P, Bockel S, Gouy S, Ba M, Achkar S, Lux F, Tillement O, Dufort S, Duc GLE, Debeaumont O, Massard C, Maulard A, Porcel E, Bahleda R, Ammari S, Morel D, Espenel S, Pautier P, Robert C, Deutsch E. Theragnostic Gadolinium-Based Nanoparticles Safely Augment X-ray Radiation Effects in Patients with Cervical Cancer. ACS NANO 2024; 18:16516-16529. [PMID: 38912600 DOI: 10.1021/acsnano.3c12537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Activated guided irradiation by X-ray (AGuIX) nanoparticles are gadolinium-based agents that have the dual benefit of mimicking the effects of a magnetic resonance imaging (MRI) contrast agent used in a clinical routine and enhancing the radiotherapeutic activity of conventional X-rays (for cancer treatment). This "theragnostic" action is explained on the one hand by the paramagnetic properties of gadolinium and on the other hand by the generation of high densities of secondary radiation following the interaction of ionizing radiation and high-Z atoms, which leads to enhanced radiation dose deposits within the tumors where the nanoparticles accumulate. Here, we report the results of a phase I trial that aimed to assess the safety and determine the optimal dose of AGuIX nanoparticles in combination with chemoradiation and brachytherapy in patients with locally advanced cervical cancer. AGuIX nanoparticles were administered intravenously and appropriately accumulated within tumors on a dose-dependent manner, as assessed by T1-weighted MRI, with a rapid urinary clearance of uncaught nanoparticles. We show that the observed tumor accumulation of the compounds can support precise delineation of functional target volumes at the time of brachytherapy based on gadolinium enhancement. AGuIX nanoparticles combined with chemoradiation appeared well tolerated among the 12 patients treated, with no dose-limiting toxicity observed. Treatment yielded excellent local control, with all patients achieving complete remission of the primary tumor. One patient had a distant tumor recurrence. These results demonstrate the clinical feasibility of using theranostic nanoparticles to augment the accuracy of MRI-based treatments while focally enhancing the radiation activity in tumors.
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Affiliation(s)
- Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- INSERM1030 Molecular Radiotherapy and Therapeutic Innovation Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Pauline Maury
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- INSERM1030 Molecular Radiotherapy and Therapeutic Innovation Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Matthieu Texier
- Biostatistics Unit, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Catherine Genestie
- Department of Pathology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Philippe Morice
- Department of Surgery, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Sophie Bockel
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- INSERM1030 Molecular Radiotherapy and Therapeutic Innovation Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Sébastien Gouy
- Department of Surgery, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Mouhamadou Ba
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Samir Achkar
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - François Lux
- Institut Lumière-Matière, UMR 5306, Université Lyon1-CNRS, Université de Lyon, Villeurbanne Cedex 69622 Villeurbanne, France
- Institut Universitaire de France, 75231 Paris, France
| | - Olivier Tillement
- Institut Lumière-Matière, UMR 5306, Université Lyon1-CNRS, Université de Lyon, Villeurbanne Cedex 69622 Villeurbanne, France
| | | | | | | | - Christophe Massard
- Université Paris-Saclay, CNRS, Institut des Sciences Moléculaires d'Orsay, 91405 Orsay, France
- Département d'Innovation Thérapeutique et d'Essais Précoces, Gustave Roussy Cancer Campus, Villejuif 94805, France
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- University Paris-Saclay Faculty of Medicine, Le Kremlin, Bicêtre 94270, France
| | - Amandine Maulard
- Department of Pathology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Erika Porcel
- Université Paris-Saclay, CNRS, Institut des Sciences Moléculaires d'Orsay, 91405 Orsay, France
| | - Ratislav Bahleda
- Département d'Innovation Thérapeutique et d'Essais Précoces, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Samy Ammari
- Department of Radiology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Daphné Morel
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- INSERM1030 Molecular Radiotherapy and Therapeutic Innovation Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Sophie Espenel
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Patricia Pautier
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
| | - Charlotte Robert
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- INSERM1030 Molecular Radiotherapy and Therapeutic Innovation Gustave Roussy Cancer Campus, Villejuif 94805, France
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- University Paris-Saclay Faculty of Medicine, Le Kremlin, Bicêtre 94270, France
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- INSERM1030 Molecular Radiotherapy and Therapeutic Innovation Gustave Roussy Cancer Campus, Villejuif 94805, France
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Villejuif 94805, France
- University Paris-Saclay Faculty of Medicine, Le Kremlin, Bicêtre 94270, France
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Roumeliotis M, Thind K, Morrison H, Burke B, Martell K, van Dyke L, Barbera L, Quirk S. The impact of advancing the standard of care in radiotherapy on operational treatment resources. J Appl Clin Med Phys 2024; 25:e14363. [PMID: 38634814 PMCID: PMC11244663 DOI: 10.1002/acm2.14363] [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: 12/15/2023] [Revised: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE To demonstrate the impact of implementing hypofractionated prescription regimens and advanced treatment techniques on institutional operational hours and radiotherapy personnel resources in a multi-institutional setting. The study may be used to describe the impact of advancing the standard of care with modern radiotherapy techniques on patient and staff resources. METHODS This study uses radiation therapy data extracted from the radiotherapy information system from two tertiary care, university-affiliated cancer centers from 2012 to 2021. Across all patients in the analysis, the average fraction number for curative and palliative patients was reported each year in the decade. Also, the institutional operational treatment hours are reported for both centers. A sub-analysis for curative intent breast and lung radiotherapy patients was performed to contextualize the impact of changes to imaging, motion management, and treatment technique. RESULTS From 2012 to 2021, Center 1 had 42 214 patient plans and Center 2 had 43 252 patient plans included in the analysis. Averaged over both centers across the decade, the average fraction number per patient decreased from 6.9 to 5.2 (25%) and 21.8 to 17.2 (21%) for palliative and curative patients, respectively. The operational treatment hours for both institutions increased from 8 h 15 min to 9 h 45 min (18%), despite a patient population increase of 45%. CONCLUSION The clinical implementation of hypofractionated treatment regimens has successfully reduced the radiotherapy workload and operational treatment hours required to treat patients. This analysis describes the impact of changes to the standard of care on institutional resources.
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Affiliation(s)
- Michael Roumeliotis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kundan Thind
- Henry Ford Cancer Institute, Detroit, Michigan, USA
| | - Hali Morrison
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Ben Burke
- University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Martell
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | - Lisa Barbera
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Sarah Quirk
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Harvard Medical School, Boston, Massachusetts, USA
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Romano A, Votta C, Nardini M, Chiloiro G, Panza G, Boldrini L, Cusumano D, Galofaro E, Placidi L, Antonelli MV, Turco G, Autorino R, Gambacorta MA. Uterus motion analysis for radiotherapy planning optimization. The innovative contribution of on-board hybrid MR imaging. Clin Transl Radiat Oncol 2024; 47:100808. [PMID: 39005509 PMCID: PMC11239475 DOI: 10.1016/j.ctro.2024.100808] [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: 12/21/2023] [Revised: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 07/16/2024] Open
Abstract
Introduction Organ motion (OM) and volumetric changes pose challenges in radiotherapy (RT) for locally advanced cervical cancer (LACC). Magnetic Resonance-guided Radiotherapy (MRgRT) combines improved MRI contrast with adaptive RT plans for daily anatomical changes. Our goal was to analyze cervico-uterine structure (CUS) changes during RT to develop strategies for managing OM. Materials and methods LACC patients received chemoradiation by MRIdian system with a simultaneous integrated boost (SIB) protocol. Prescription doses of 55-50.6 Gy at PTV1 and 45-39.6 Gy at PTV2 were given in 22 and 25 fractions. Daily MRI scans were co-registered with planning scans and CUS changes were assessed.Six PTVs were created by adding 0.5, 0.7, 1, 1.3, 1.5, and 2 cm margins to the CUS, based on the simulation MRI. Adequate margins were determined to include 95 % of the CUSs throughout the entire treatment in 95 % of patients. Results Analysis of 15 LACC patients and 372 MR scans showed a 31 % median CUS volume decrease. Asymmetric margins of 2 cm cranially, 0.5 cm caudally, 1.5 cm posteriorly, 2 cm anteriorly, and 1.5 cm on both sides were optimal for PTV, adapting to CUS variations. Post-14th fraction, smaller margins of 0.7 cm cranially, 0.5 cm caudally, 1.3 cm posteriorly, 1.3 cm anteriorly, and 1.3 cm on both sides sufficed. Conclusion CUS mobility varies during RT, suggesting reduced PTV margins after the third week. MRgRT with adaptive strategies optimizes dose delivery, emphasizing the importance of streamlined IGRT with reduced PTV margins using a tailored MRgRT workflow with hybrid MRI-guided systems.
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Affiliation(s)
- Angela Romano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Claudio Votta
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giulia Panza
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, 07026 Olbia, Italy
| | - Elena Galofaro
- Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Marco Valerio Antonelli
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Gabriele Turco
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Rosa Autorino
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
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Kashid SR, Gurram L, Pullan S, Chopra S, Mittal P, Ghadi Y, Dheera A, Scaria L, Kohle S, Kadam S, Ghosh J, Rath S, Gupta S, Mahantshetty U. Clinical outcomes of adaptive intracavitary and interstitial brachytherapy technique in locally advanced cervical cancer: A real-world data. Brachytherapy 2024; 23:407-415. [PMID: 38641455 DOI: 10.1016/j.brachy.2024.03.006] [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: 02/04/2024] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/21/2024]
Abstract
PURPOSE To evaluate clinical outcomes of CT-based adaptive intracavitary and interstitial brachytherapy (IC followed by IC-ISBT) in locally advanced cervical cancer (LACC) in resource-constrained settings. METHODS AND MATERIALS LACC patients treated with adaptive brachytherapy techniques were analyzed to evaluate treatment characteristics and clinical outcomes. The Kaplan-Meier method was used for survival analysis, and the log-rank test for univariate analysis. RESULTS Out of 141 eligible patients with LACC, 87 (61.7%) patients received external beam radiotherapy (EBRT) in referral hospitals, while 54 (38.3%) were treated at our center. We divided our cohort into two groups: poor EBRT responder group (n = 70 [49.6%]) where IC-ISBT was adapted to achieve optimum tumor doses and OAR optimization group 71 (50.4%) where IC-ISBT was performed to reduce OAR doses. Median HRCTV-D90 dose was 88 Gy (range 70-109 Gy) with median HRCTV volume 33cc (range 15-96). Median D2cc doses to OARs were 90 Gy (range 70-107), 71 Gy (range 55-105) and 70 Gy (range 47-90) to bladder, rectum and sigmoid, respectively. At median follow-up of 32 months, 3-year local control (LC), locoregional control (LRC), disease-free survival (DFS) and overall survival (OS) were 83%, 75%, 64% and 72%, respectively. Subgroup analysis revealed significantly better outcomes for OAR optimization compared to poor EBRT responders, with 3-year LC (95% vs. 70.1%, p < 0.001), LRC (87.3% vs. 62.7%, p < 0.001), DFS (79.2% vs. 49.4%, p < 0.001), and OS (86.2% vs. 57.4%, p < 0.001) CONCLUSION: In resource-constrained settings, implementation of Adaptive IC-ISBT is a viable alternative for optimizing OAR doses in LACC. However proactive approach employing IC-ISBT for tumor dose-escalation from first fraction of BT is warranted for improving LC in poor EBRT responders.
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Affiliation(s)
- Sheetal R Kashid
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Lavanya Gurram
- Advanced Radiation Oncology Fellow, Department of Radiation Oncology, CancerCare Manitoba, Canada.
| | - Saritha Pullan
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Prachi Mittal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Yogesh Ghadi
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - A Dheera
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Libin Scaria
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Satish Kohle
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sudarshan Kadam
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jaya Ghosh
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sushmita Rath
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Umesh Mahantshetty
- Homi Bhabha Cancer Hospital, Visakhapatnam, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Houdou L, Meynard C, Guillerm S, Mimoun C, Lambert T, Marchand E, Jornet D, Fumagalli I, Quero L, Huchon C, Hennequin C. Monocentric Retrospective Study: Efficacy, Feasibility, and Prognostic Factors of Single-Insertion High-Dose-Rate Brachytherapy With 4 Sessions for Locally Advanced Cervical Cancer. Adv Radiat Oncol 2024; 9:101512. [PMID: 38883995 PMCID: PMC11177070 DOI: 10.1016/j.adro.2024.101512] [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: 11/27/2023] [Accepted: 04/02/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose This study aims to assess the feasibility and efficacy of high-dose rate (HDR) brachytherapy (BT) administered in a single insertion with 4 treatment sessions for locally advanced cervical cancer and to identify the prognostic factors influencing outcomes. Methods and Materials We retrospectively analyzed the clinical data of patients with cervical cancer with locally advanced disease (International Federation of Gynecology and Obstetrics 2018 IB-IVB) treated at our institution from January 2014 through December 2021. Each patient received definitive radiation therapy with an external irradiation dosage between 45 and 50.4 Gy along with concurrent chemotherapy. HDR-BT (24 Gy) was prescribed to a high-risk clinical target volume. Results One hundred thirty-nine patients were included and the HDR-BT program could be fully performed in 136 patients (98%). Over a median follow-up duration of 40.5 months, the 2-year local control (LC), overall survival (OS), and disease-free survival rates stood at 79.4%, 77.7%, and 61.7%, respectively, with 5-year rates at 78.2%, 61.6%, and 55.7%. Multivariate analysis revealed the primary determinant of LC as the tumor's response to external beam radiation therapy as determined via magnetic resonance imaging before BT. Parametrial involvement demonstrated a significant multivariate association with disease-free survival (P = .04). Regarding OS, parametrial invasion (P = .01) and the tumor's response postchemoradiotherapy (P = .02) emerged as significant factors. Regarding chronic toxicities, 18% (25 patients) experienced grade 3 complications. An optimal D2 cc (bowel) threshold of 70 Gy (P = .001) was identified to limit chronic digestive complications of grade 3 or higher. Conclusions The implementation of single-insertion, 4-session HDR-BT could be performed in 98% of the patients. It yields favorable LC and OS rates, coupled with tolerable toxicity in patients with locally advanced cervical cancer. Response to initial chemoradiotherapy evaluated on pre-BT magnetic resonance imaging is an important prognostic factor and could help to individualize therapeutic strategies.
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Affiliation(s)
- Lucie Houdou
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
| | - Claire Meynard
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
| | - Sophie Guillerm
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
| | - Camille Mimoun
- Gynecologic Department, Lariboisière Hospital, Paris, France
| | - Tiphaine Lambert
- Medical Oncology Department, Saint-Louis Hospital, Paris, France
| | - Eva Marchand
- Gynecologic Department, Lariboisière Hospital, Paris, France
| | - Diane Jornet
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
| | - Ingrid Fumagalli
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
| | - Laurent Quero
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
- University of Paris-Cité, Cancer Institute of Oncology, Paris-Nord
| | - Cyrille Huchon
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
- University of Paris-Cité, Cancer Institute of Oncology, Paris-Nord
| | - Christophe Hennequin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France
- University of Paris-Cité, Cancer Institute of Oncology, Paris-Nord
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Portocarrero-Bonifaz A, Syed S, Kassel M, McKenzie GW, Shah VM, Forry BM, Gaskins JT, Sowards KT, Avula TB, Masters A, Silva SR. Dosimetric and toxicity comparison between Syed-Neblett and Fletcher-Suit-Delclos Tandem and Ovoid applicators in high dose rate cervix cancer brachytherapy. Brachytherapy 2024; 23:397-406. [PMID: 38643046 DOI: 10.1016/j.brachy.2024.03.003] [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: 12/20/2023] [Revised: 02/21/2024] [Accepted: 03/06/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE To compare patient and tumor characteristics, dosimetry, and toxicities between interstitial Syed-Neblett and intracavitary Fletcher-Suit-Delclos Tandem and Ovoid (T&O) applicators in high dose rate (HDR) cervical cancer brachytherapy. METHODS A retrospective analysis was performed for cervical cancer patients treated with 3D-based HDR brachytherapy from 2011 to 2023 at a single institution. Dosimetric parameters for high-risk clinical target volume and organs at risk were obtained. Toxicities were evaluated using the Common Terminology Criteria for Adverse Events version 5.0. RESULTS A total of 115 and 58 patients underwent Syed and T&O brachytherapy, respectively. Patients treated with Syed brachytherapy were more likely to have larger tumors and FIGO stage III or IV disease. The median D2cc values to the bladder, small bowel, and sigmoid colon were significantly lower for Syed brachytherapy. Patients treated with Syed brachytherapy were significantly more likely to be free of acute gastrointestinal (44% vs. 21%, p = 0.003), genitourinary (58% vs. 36%, p = 0.01), and vaginal toxicities (60% vs. 33%, p = 0.001) within 6 months following treatment compared to patients treated with T&O applicators. In contrast, Syed brachytherapy patients were more likely to experience late gastrointestinal (68% vs. 49%, p = 0.082), genitourinary (51% vs. 35%, p = 0.196), and vaginal toxicities (70% vs. 57%, p = 0.264). CONCLUSIONS Syed-Neblett and T&O applicators are suitable for HDR brachytherapy for cervical cancer in distinct patient populations. Acute toxicities are more prevalent with T&O applicators, while patients treated with Syed-Neblett applicators are more likely to develop late toxicities.
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Affiliation(s)
- Andres Portocarrero-Bonifaz
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY; Physics Department, Pontificia Universidad Catolica del Peru, Lima, Peru.
| | - Salman Syed
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Maxwell Kassel
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Grant W McKenzie
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Vishwa M Shah
- Department of Gynecologic Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Bryce M Forry
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Jeremy T Gaskins
- Department of Bioinformatics & Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, KY
| | - Keith T Sowards
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Thulasi Babitha Avula
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Adrianna Masters
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Scott R Silva
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
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Endo Y, Soeda S, Yoshimoto Y, Todate Y, Hashimoto T, Furukawa S, Teranishi Y, Fujimori K. Successful management of locally advanced cervical cancer via total pelvic exenteration following neoadjuvant chemotherapy. J Surg Case Rep 2024; 2024:rjae452. [PMID: 38993818 PMCID: PMC11238252 DOI: 10.1093/jscr/rjae452] [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: 05/29/2024] [Accepted: 06/29/2024] [Indexed: 07/13/2024] Open
Abstract
Stage IVA cervical cancer is a tumor that invades the mucosa of the bladder or rectum without distant metastasis and is difficult to treat, and concurrent chemoradiotherapy is recommended. Although radical surgery following neoadjuvant chemotherapy is a treatment option for stage IVA cervical cancer, the evidence is limited. A 51-year-old woman with bulky cervical cancer and rectal invasion was referred to our hospital. Paclitaxel and cisplatin were administered as neoadjuvant chemotherapies. After two cycles of chemotherapy, the tumor size decreased markedly. Total pelvic exenteration was performed, and a complete resection was achieved. Four cycles of paclitaxel and cisplatin were administered postoperatively. Thirty-three months after the completion of adjuvant chemotherapy, the patient was alive and free of disease. Radical surgery after neoadjuvant chemotherapy may be a treatment option for stage IVA cervical cancer with bulky tumors.
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Affiliation(s)
- Yuta Endo
- Department of Gynecology, Southern Tohoku General Hospital, 7-115 Yatsuyamada, Koriyama, Fukushima 963-8563, Japan
- Department of Reginal Gynecologic Oncology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
| | - Shu Soeda
- Department of Reginal Gynecologic Oncology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
| | - Yuki Yoshimoto
- Department of Gynecology, Southern Tohoku General Hospital, 7-115 Yatsuyamada, Koriyama, Fukushima 963-8563, Japan
| | - Yukitoshi Todate
- Department of Surgery, Southern Tohoku General Hospital, 7-115, Yatsuyamada, Koriyama, Fukushima 963-8563, Japan
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
| | - Tatsuru Hashimoto
- Department of Urology, Southern Tohoku General Hospital, 7-115 Yatsuyamada, Koriyama, Fukushima 963-8563, Japan
| | - Shigenori Furukawa
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
- Department of Regional Medical Support for Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
| | - Yasushi Teranishi
- Department of Surgery, Southern Tohoku General Hospital, 7-115, Yatsuyamada, Koriyama, Fukushima 963-8563, Japan
| | - Keiya Fujimori
- Department of Reginal Gynecologic Oncology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
- Department of Regional Medical Support for Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
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Muramoto Y, Murakami N, Okonogi N, Takatsu J, Iijima K, Inoue T, Kato K, Karino T, Kojima K, Oshima M, Kosugi Y, Kawamoto T, Hirayama T, Fujino K, Terao Y, Shikama N. Dose Contribution to the Regional Lymph-Node Metastases and Point B from Intracavity and Interstitial Hybrid Brachytherapy in Locally Advanced Cervical Cancer. Cancers (Basel) 2024; 16:2384. [PMID: 39001446 PMCID: PMC11240443 DOI: 10.3390/cancers16132384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/24/2024] [Accepted: 06/25/2024] [Indexed: 07/16/2024] Open
Abstract
PURPOSE Analyzing dose distributions to regional lymph-node metastases (RLNMs) in locally advanced cervical cancer (LACC) patients undergoing intracavitary and interstitial hybrid brachytherapy (IC/IS). METHODS Dose distributions of eleven LACC patients with 38 RLNMs, and who received 38 IC/IS sessions were analyzed in EQD2, considering RLNM positions and ipsilateral interstitial needles; these RLNMs, excepting the para-aortic region, were classified into four groups. RESULTS RLNMs had a median of two ipsilateral interstitial needles per session. Significant differences were observed in total RLNM D90, depending on whether the position was cranial or caudal of the uterine base (85.5 vs. 378.9 cGy, p < 0.0001), and whether the RLNM D90 was associated with a number of ipsilateral interstitial needles between 0-1 or 2 or more (68.4 vs. 112.2 cGy, p = 0.006) per session. At each session, Group 1 RLNMs (cranial of the uterine base, 0-1 ipsilateral interstitial needle) had a mean D90 of 21.1 cGy; Group 2 (cranial, 2 or more), 73.8; Group 3 (caudal, 0-1), 94.7; and Group 4 (caudal, 2 or more), 136.1. CONCLUSION RLNMs located caudal of the uterine base associated with two or more ipsilateral interstitial needles in IC/IS had a higher dose contribution, which should be considered when calculating the RLNMs' dose of external beam boost irradiation.
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Affiliation(s)
- Yoichi Muramoto
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Naoya Murakami
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Noriyuki Okonogi
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Jun Takatsu
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Kotaro Iijima
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Tatsuya Inoue
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Kanade Kato
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Tatsuki Karino
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Kanako Kojima
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Masaki Oshima
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Yasuo Kosugi
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
| | - Takashi Hirayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Kazunari Fujino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (Y.M.); (T.K.)
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Chuk E, Yu C, Scott AA, Liu ZA, Milosevic M, Croke J, Fyles A, Lukovic J, Rink A, Beiki-Ardakani A, Borg J, Skliarenko J, Conway JL, Weersink RA, Han K. Clinical Outcomes of 3 Versus 4 Fractions of Magnetic Resonance Image-Guided Brachytherapy in Cervical Cancer. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00745-4. [PMID: 38936633 DOI: 10.1016/j.ijrobp.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/30/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Magnetic resonance image-guided brachytherapy is essential in the management of locally advanced cervical cancer. This study compares disease and toxicity outcomes in cervical cancer patients treated with 24 Gy/3 fractions (Fr) versus the conventional 28 Gy/4 Fr. METHODS AND MATERIALS This retrospective study included 241 consecutive patients with International Federation of Gynecology and Obstetrics 2018 stage IB to IVA cervical cancer treated with definitive chemoradiation between April 2014 and March 2021. Disease-free survival (DFS) was estimated using the Kaplan-Meier method and compared using the log-rank test. Cumulative incidence of local failure (LF), distant failure (DF), and G2+ gastrointestinal (GI), urinary and vaginal toxicity were estimated using the cumulative incidence function with death as a competing risk and compared using Gray's test. RESULTS Of the 241 patients, 42% received 24 Gy/3 Fr and 58% received 28 Gy/4 Fr. With a median follow-up of 3.2 (range, 0.2-9.2) years, there were 14 local, 41 regional nodal, and 51 distant failures in 63 (26%) patients. No significant differences were found between the 24 Gy/3 Fr and 28 Gy/4 Fr groups in 3-year DFS (77% vs 68%, P = .21), the 3-year cumulative incidence of LF (5% vs 7%, P = .57), DF (22% vs 25%, P = .86), G2+ GI toxicity (11% vs 20%, P = .13), or G2+ vaginal toxicity (14% vs 17%, P = .48), respectively. The 3-year cumulative G2+ urinary toxicity rate was lower in the 24 Gy/3 Fr group (9% vs 23%, P = .03). CONCLUSIONS Patients with cervical cancer treated with 24 Gy/3 Fr had similar DFS, LF, DF, GI, and vaginal toxicity rates and a trend toward a lower G2+ urinary toxicity rate compared with those treated with 28 Gy/4 Fr. A less resource-intensive brachytherapy fractionation schedule of 24 Gy/3 Fr is a safe alternative to 28 Gy/4 Fr for definitive treatment of cervical cancer.
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Affiliation(s)
- Elizabeth Chuk
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Candice Yu
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Aba Anoa Scott
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Michael Milosevic
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Jennifer Croke
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Anthony Fyles
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jelena Lukovic
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alexandra Rink
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Akbar Beiki-Ardakani
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jette Borg
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Julia Skliarenko
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jessica L Conway
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Robert A Weersink
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Kathy Han
- Princess Margaret Cancer Centre, University Health Network, Radiation Medicine Program, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada.
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Wang Y, Zhang F, Hu K, Yu L, Zhang J, Luo C, Yu L, Yan J. CT-guided hydrogel injection for brachytherapy in cervical cancer: A case report. Med Dosim 2024:S0958-3947(24)00024-4. [PMID: 38902140 DOI: 10.1016/j.meddos.2024.04.006] [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: 07/16/2023] [Revised: 04/03/2024] [Accepted: 04/23/2024] [Indexed: 06/22/2024]
Abstract
Rectal toxicity is a significant concern in cervical cancer radiotherapy. Despite advancements in image-guided brachytherapy (IGBT), rectal morbidity remains a challenge. Injectable hydrogel showed promise in creating a space between the vagina and rectum, reducing rectal radiation dose; however, the traditional ultrasound-guided injection revealed some problems, such as the inadequate separation of the upper edge of the cervix, which can be mitigated through adopting CT-guided injection. This case report presents the successful use of computed tomography (CT)-guided hydrogel injection to limit rectal doses and improve treatment outcomes. A forty-year-old female with stage IIIC1r cervical cancer received external-beam radiotherapy and concurrent chemotherapy. Due to the proximity of the tumor to the rectum, a CT-guided hydrogel injection was performed to increase the distance between the cervix and rectum. Post-injection, magnetic resonance imaging (MRI) demonstrated increased distances between the cervix and rectum. Subsequent MRI-based IGBT achieved high clinical target volume doses while limiting rectal doses. During the six-month follow-up, the patient reported only mild adverse effects. CT-guided hydrogel injection offers advantages over ultrasound-guided injection in cervical cancer radiotherapy. The technique allows for better puncture position adjustment, reduced reliance on specialized ultrasound expertise, and shorter puncture distances. This case report highlights the potential of hydrogel injection as a viable method to reduce rectal morbidity and improve treatment outcomes in a broader range of cervical cancer patients. Further studies are warranted to validate these findings and explore its applicability in larger cohorts.
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Affiliation(s)
- Yuxuan Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China; Peking Union Medical College, Beijing 100730, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China; Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Jie Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Chunli Luo
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Lihua Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
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Yamada T, Kawamura M, Oie Y, Kozai Y, Okumura M, Nagai N, Yanagi Y, Nimura K, Ishihara S, Naganawa S. The current state and future perspectives of radiotherapy for cervical cancer. J Obstet Gynaecol Res 2024. [PMID: 38885951 DOI: 10.1111/jog.15998] [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: 04/23/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024]
Abstract
Radiotherapy is an effective treatment method for cervical cancer and is typically administered as external beam radiotherapy followed by intracavitary brachytherapy. In Japan, center shielding is used in external beam radiotherapy to shorten treatment time and reduce the doses delivered to the rectum or bladder. However, it has several challenges, such as uncertainties in calculating the cumulative dose. Recently, external beam radiotherapy has been increasingly performed with intensity-modulated radiotherapy, which reduces doses to the rectum or bladder without center shielding. In highly conformal radiotherapy, uncertainties in treatment delivery, such as inter-fractional anatomical structure movements, affect treatment outcomes; therefore, image-guided radiotherapy is essential for appropriate and safe performance. Regarding intracavitary brachytherapy, the use of magnetic resonance imaging-based image-guided adaptive brachytherapy is becoming increasingly widespread because it allows dose escalation to the tumor and accurately evaluates the dose delivered to the surrounding normal organs. According to current evidence, a minimal dose of D90% of the high-risk clinical target volume is significantly relevant to local control. Further improvements in target coverage have been achieved with combined interstitial and intracavity brachytherapy for massive tumors with extensive parametrical involvement. Introducing artificial intelligence will enable faster and more accurate generation of brachytherapy plans. Charged-particle therapies have biological and dosimetric advantages, and current evidence has proven their effectiveness and safety in cervical cancer treatment. Recently, radiotherapy-related technologies have advanced dramatically. This review provides an overview of technological innovations and future perspectives in radiotherapy for cervical cancer.
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Affiliation(s)
- Takehiro Yamada
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yumi Oie
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuka Kozai
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Okumura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoya Nagai
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Yanagi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Radiology, Toyota Memorial Hospital, Toyota, Japan
| | - Kenta Nimura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Radiology, Tosei General Hospital, Seto, Japan
| | - Shunichi Ishihara
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Wang Z, Guo X, Zhao H. Dose-response relationship between volume base dose and tumor local control in definitive radiotherapy for vaginal cancer. BMC Cancer 2024; 24:707. [PMID: 38851692 PMCID: PMC11162573 DOI: 10.1186/s12885-024-12486-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/07/2024] [Indexed: 06/10/2024] Open
Abstract
OBJECTIVE This study aimed to establish the dose-response relationship between volume base dose and tumor local control for vaginal cancer, including primary vaginal cancer and recurrent gynecologic malignancies in the vagina. MATERIALS AND METHODS We identified studies that reported volume base dose and local control by searching the PubMed, the Web of Science, and the Cochrane Library Database through August 12, 2023. The regression analyses were performed using probit model between volume based dose versus clinical outcomes. Subgroup analyses were performed according to stratification: publication year, country, inclusion time of patients, patients with prior radiotherapy, age, primaries or recurrent, tumor size, concurrent chemoradiotherapy proportion, dose rate, image modality for planning, and interstitial proportion. RESULTS A total of 879 patients with vaginal cancer were identified from 18 studies. Among them, 293 cases were primary vaginal cancer, 573 cases were recurrent cancer in the vagina, and 13 cases were unknown. The probit model showed a significant relationship between the HR-CTV (or CTV) D90 versus the 2-year and 3-year local control, P values were 0.013 and 0.014, respectively. The D90 corresponding to probabilities of 90% 2-year local control were 79.0 GyEQD2,10 (95% CI: 75.3-96.6 GyEQD2,10). CONCLUSIONS A significant dependence of 2-year or 3-year local control on HR-CTV (or CTV) D90 was found. Our research findings encourage further validation of the dose-response relationship of radical radiotherapy for vaginal cancer through protocol based multicenter clinical trials.
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Affiliation(s)
- Zhiqiang Wang
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, PR China
| | - Xin Guo
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, PR China
| | - Hongfu Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, PR China.
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Charnalia M, Chopra S, Mulani J, Popat P, Rath S, Thomeer M, Mittal P, Gupta A, Boere I, Gupta S, Nout RA. RECIST 1.1 versus clinico-radiological response assessment for locally advanced cervical cancer: implications on interpreting survival outcomes of future trials. Int J Gynecol Cancer 2024; 34:817-823. [PMID: 38649234 DOI: 10.1136/ijgc-2024-005336] [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] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE To investigate differences in standard clinico-radiological evaluation versus Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 for reporting survival outcomes in patients with locally advanced cervical cancer treated with chemoradiation and brachytherapy. METHODS Between November 2017 and March 2020, patients recruited in cervical cancer trials were identified. MRI at diagnosis and at least one follow-up imaging was mandatory. Disease-free survival and progression-free survival were determined using standard evaluation (clinical examination and symptom-directed imaging) and RECIST 1.1. Agreement between criteria was estimated using κ value. Sensitivity analysis was done to test the sensitivity, specificity, and accuracy of RECIST 1.1 in detecting response to treatment. RESULTS Sixty-nine eligible patients had at least one target lesion. Thirty-three patients (47.8%) had pathological lymph nodes. Of these 33 patients, RECIST 1.1 classified only 18% (6/33) as 'target nodal lesions' and the remaining nodes as 'non-target'. There were 6 (8.7%) and 8 (11.6%) patients with disease events using RECIST 1.1 and standard evaluation, respectively. The disease-free survival at 12, 18, and 24 months using RECIST 1.1 was 94.2%, 91.2%, 91.2%, and with standard evaluation was 94.2%, 89.7%, and 88.2%, respectively (p=0.58). Whereas, progression-free survival at 12, 18, and 24 months using RECIST 1.1 and standard evaluation were same (94.2%, 91.2%, and 91.2%, respectively). The κ value was 0.84, showing strong agreement in assessing disease-free survival, although an absolute difference of 3% between endpoint assessment methodologies. RECIST 1.1 had a sensitivity of 75% (95% CI 34.91% to 96.81%), specificity of 100% (95% CI 94.13% to 100%), and accuracy of 97.1% (95% CI 89.92% to 99.65%). CONCLUSIONS The study showed 1.5% and 3% difference in disease-free survival at 18 and 24 months and no difference in progression-free survival between RECIST 1.1 and standard evaluation in a patient cohort with low event rate.
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Affiliation(s)
- Mayuri Charnalia
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, Maharashtra, India
| | - Jaahid Mulani
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, Maharashtra, India
| | - Palak Popat
- Department of Radiodiagnosis, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sushmita Rath
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maarten Thomeer
- Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Centre, Rotterdam, Zuid-Holland, Netherlands
| | - Prachi Mittal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ankita Gupta
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, Maharashtra, India
| | - Ingrid Boere
- Department of Medical Oncology, Erasmus MC Cancer Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Sudeep Gupta
- Department of Medical Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, Maharashtra, India
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, Zuid-Holland, Netherlands
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Guigo M, Dauda MS, Lequesne J, Blache A, Pereira R, Le Gall I, Pernin VE, Gaichies L, Clarisse B, Grellard JM, Joly F, Meyer E, Balosso J. Simultaneous integrated boost on pathologic lymph nodes safely improves clinical outcomes compared to sequential boost in locally advanced cervical cancer: a multicenter retrospective study. Front Oncol 2024; 14:1353813. [PMID: 38887236 PMCID: PMC11180790 DOI: 10.3389/fonc.2024.1353813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024] Open
Abstract
Background Objective This multicenter study aimed to retrospectively evaluate the impact of high boost simultaneous integrated boost (SIB) to pathologic lymph nodes compared to Sequential boost (Seq) in patients with locally advanced cervical cancer (LACC). Materials and methods 97 patients with pelvic and/or para-aortic (PAo) node-positive LACC treated by definitive chemoradiation were included. Two groups were analyzed: Sequential boost group and simultaneous integrated boost (SIB) group. Endpoints were Distant Recurrence Free Survival (DRFS), Recurrence Free Survival (RFS), Overall Survival (OS), locoregional pelvic and PAo control and toxicities. Results 3-years DRFS in SIB and Seq groups was 65% and 31% respectively (log-rank p < 0.001). 3-years RFS was 58% and 26% respectively (log-rank p = 0.009). DRFS prognostic factors in multivariable analysis were SIB, PAo involvement and maximum pelvic node diameter ≥ 2cm. Adenocarcinoma histology and absence of brachytherapy tended to be prognostic factors. SIB provided the best pelvic control at first imaging with 97%. There was no significant difference in terms of toxicities between groups. Conclusions Nodal SIB seems to be unavoidable in the treatment of node-positive LACC. It provides the best DRFS, RFS and pelvic control without additional toxicity, with a shortened treatment duration.
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Affiliation(s)
- Marin Guigo
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
| | | | - Justine Lequesne
- Clinical Research Department, Centre François Baclesse, Caen, France
| | - Alice Blache
- Department of Radiation Oncology, Centre Hospitalier Universitaire (CHU) Amiens-Picardie, Amiens, France
| | - Renata Pereira
- Department of Radiation Oncology, Centre Guillaume Le Conquérant, Le Havre, France
| | - Ioana Le Gall
- Department of Radiation Oncology, Centre de la Baie, Avranches, France
| | | | | | | | | | - Florence Joly
- Clinical Research Department, Centre François Baclesse, Caen, France
- Institut National de la Santé Et de la Recherche Médicale (INSERM), U1086, ANTICIPE, Cancer and Cognition Platform, Ligue Nationale Contre le Cancer, Medical Oncology Department, Centre François Baclesse, Caen, France
| | - Emmanuel Meyer
- Department of Radiation Oncology, Centre Maurice Tubiana, Caen, France
| | - Jacques Balosso
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
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Isohashi F, Yoshida K, Murakami N, Masui K, Ishihara S, Ohkubo Y, Kaneyasu Y, Kinoshita R, Kotsuma T, Takaoka Y, Tanaka E, Nagao A, Ogawa K, Yamazaki H. Reirradiation for recurrent gynecologic cancer using high-dose-rate brachytherapy in Japan: A multicenter survey on practice patterns and outcomes. Radiother Oncol 2024; 195:110269. [PMID: 38583719 DOI: 10.1016/j.radonc.2024.110269] [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: 11/09/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE The aim of the study is to examine the present status of reirradiation with high-dose-rate (HDR) brachytherapy for recurrent gynecologic cancer in Japan and to determine the role of this therapy in clinical practice. MATERIALS AND METHODS A retrospective multicenter chart review was performed for reirradiation for gynecologic cancer using HDR brachytherapy. Each center provided information on patient characteristics, treatment outcomes, and complications. RESULTS The study included 165 patients treated at 9 facilities from 2000 to 2018. The analysis of outcomes included 142 patients treated with curative intent. The median follow-up time for survivors was 30 months (range 1-130 months). The 3-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 53 % (95 %CI: 42-63 %), 44 % (35-53 %), and 61 % (50-70 %) for cervical cancer; 100 % (NA), 64 % (30-85 %), and 70 % (32-89 %) for endometrial cancer; and 54 % (13-83 %), 38 % (6-72 %), and 43 % (6-78 %) for vulvar and vaginal cancer, respectively. In multivariate analysis, interval to reirradiation (<1 year) was a significant risk factor for OS, PFS and LC; Gross Tumor Volume (≥25 cm3) was a significant risk factor for OS. Toxicities were analyzed in all enrolled patients (n = 165). Grade ≥ 3 late toxicities occurred in 49 patients (30 %). A higher cumulative EQD2 (α/β = 3) was significantly associated with severe complications. CONCLUSION Reirradiation with HDR brachytherapy for recurrent gynecologic cancer is effective, especially in cases with a long interval before reirradiation.
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Affiliation(s)
- Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan.
| | - Ken Yoshida
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan; Department of Radiation Oncology, Juntendo University, Hongo, Tokyo, Japan
| | - Koji Masui
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shunichi Ishihara
- Department of Radiology, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan; Department of Radiology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yu Ohkubo
- Department of Radiation Oncology, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Hiroshima, Japan; Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Hiroshima, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiation Oncology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yuji Takaoka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Saito Yukoukai Hospital, Ibaraki, Osaka, Japan
| | - Eiichi Tanaka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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