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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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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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Ohtaka T, Ando K, Oike T, Noda SE, Kaminuma T, Murata K, Ohno T. The prognostic effect of tumor volume, reduction ratio, and cumulative doses on external beam radiotherapy with central-shielding method and image-guided adaptive brachytherapy for cervical cancer. Front Oncol 2024; 14:1366777. [PMID: 38774419 PMCID: PMC11106361 DOI: 10.3389/fonc.2024.1366777] [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: 01/07/2024] [Accepted: 04/23/2024] [Indexed: 05/24/2024] Open
Abstract
Objective To evaluate the prognostic effect of tumor volume at diagnosis, tumor reduction ratio during external beam radiotherapy (EBRT) with central-shielding method, and cumulative minimal dose to 90% of the high-risk clinical target volume (CTVHR D90) on combined EBRT and image-guided adaptive brachytherapy (IGABT) for cervical cancer. Methods Consecutive patients who underwent definitive radiotherapy or concurrent chemoradiotherapy for cervical cancer at Gunma University Hospital between January 2010 and December 2019 were retrospectively reviewed. Tumor volume at diagnosis and reduction ratio were calculated using magnetic resonance imaging at diagnosis and before the first IGABT session. The cumulative dose of EBRT and IGABT was calculated as an equivalent dose in 2 Gy fractions (EQD2). Optimal cutoff values were determined according to a receiver operating characteristic curve. Treatment outcomes were evaluated using the Kaplan-Meier method and compared using the log-rank test and Cox proportional hazards regression. Results A total of 254 patients were included in the analysis. The median follow-up for all patients was 57 (2-134) months. The 5-year overall survival (OS) was 81.9%, progression-free survival (PFS) was 71.3%, and local control (LC) was 94.5%. The patients were divided into four groups according to tumor volume at diagnosis and reduction ratio. The group with tumor volume at diagnosis ≥ 34.1 cm3 and reduction ratio < 68.8% showed significantly worse OS, PFS, and LC than the other three groups (All p < 0.05). In this group, the patients with a cumulative CTVHR D90 < 69.6 GyEQD2 showed significantly worse PFS and LC (p = 0.042 and p = 0.027, respectively). In the multivariate analysis of OS, adenocarcinoma/adenosquamous carcinoma, International Federation of Gynecology and Obstetrics 2009 stage III/IV, and a reduction ratio of < 68.8% were independent significant poor prognostic factors (p = 0.045, p = 0.009 and p = 0.001, respectively). In the univariate analysis of LC, a reduction ratio of < 68.8% was the only poor prognostic factor (p = 0.041). Conclusion The patients with large and poorly responding tumors had significantly worse prognoses in terms of OS, PFS, and LC, suggesting that dose escalation should be considered for such tumors.
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Affiliation(s)
- Takeru Ohtaka
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ken Ando
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takahiro Oike
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | - Shin-ei Noda
- Department of Radiation Oncology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Takuya Kaminuma
- Department of Radiation Therapy, NHO Shibukawa Medical Center, Shibukawa, Japan
| | - Kazutoshi Murata
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
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Muramoto Y, Murakami N, Karino T, Sugimoto S, Takatsu J, Oshima M, Kosugi Y, Kawamoto T, Hirayama T, Fujino K, Terao Y, Shikama N. MucoUp® as a spacer in brachytherapy for uterine cervical cancer: A first-in-human experience. Clin Transl Radiat Oncol 2023; 42:100659. [PMID: 37519921 PMCID: PMC10372547 DOI: 10.1016/j.ctro.2023.100659] [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: 04/15/2023] [Revised: 07/03/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
We first used MucoUp®, a hyaluronic acid used in endoscopic resection, as a spacer in brachytherapy. In five cervical cancer patients, MucoUp® insertion increased a 90% dose of the high-risk CTV to over 80 Gy while decreasing the dose of organs at risk. No related adverse events were observed.
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Affiliation(s)
- Yoichi Muramoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Tatsuki Karino
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Satoru Sugimoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Jun Takatsu
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Takashi Hirayama
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Kazunari Fujino
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
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Sommat K, Yap SP, Yeo RMC, Tan HSK, Soong YL, Tuan JKL, Sin IH. Oncologic outcomes after MRI-assisted image-guided brachytherapy with hybrid interstitial and intra-cavitary applicators under moderate sedation for locally advanced cervix cancer. J Contemp Brachytherapy 2023; 15:245-252. [PMID: 37799121 PMCID: PMC10548430 DOI: 10.5114/jcb.2023.130976] [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: 04/13/2023] [Accepted: 08/04/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose To report outcomes of using image-guided hybrid intra-cavitary/interstitial applicators under moderate sedation for locally advanced cervical cancer patients in our institution. Material and methods A total of 69 fractions of brachytherapy with hybrid applicators were performed in 33 patients from January 2017 to April 2021. All patients underwent MRI pelvis 1 week pre-brachytherapy to determine suitability for interstitial brachytherapy and pre-plan needle placement. All insertion of applicators were performed under moderate sedation with midazolam and/or fentanyl. Fifty-eight (84.1%) fractions were planned with CT alone. Clinical outcomes, dose volume parameters, and toxicities were analyzed. Results The median follow-up was 28 months. A total of 320 needles (median, 5 needles per fraction) were implanted, with a median insertion depth of 3 cm (range, 1.5-4 cm). The median high-risk clinical target volume (HR-CTV) during initial brachytherapy was 34.5 cc (range, 17.8-74.7 cc). The median total EQD2 D2cc of the rectum, bladder, sigmoid, and small intestine colon was 71.8 Gy, 81.5 Gy, 69 Gy, and 58.3 Gy, respectively. The 2-year local control and overall survival were 80.7% and 77.7%, respectively. Larger volume HR-CTV was significantly associated with worse local control (HR = 1.08, p = 0.005) and overall survival (HR = 1.04, p = 0.015). None of the patients required in-patient admission or blood transfusion post-procedure. Late grade 3 gastrointestinal and genitourinary toxicities were observed in 4 patients (12.2%). Conclusions Hybrid applicators inserted under moderate sedation are feasible and safe. Image-guided interstitial brachytherapy with CT planning aided by MRI performed 1 week pre-brachytherapy is associated with favorable outcomes and modest toxicities.
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Affiliation(s)
- Kiattisa Sommat
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Swee Peng Yap
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Hoon Seng Khoo Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Yoke Lim Soong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Iris Huili Sin
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
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Murakami N, Okuma K, Takahashi A, Kato T, Igaki H. Is it time to modify the Japanese Uterine Cervical Cancer Guidelines to recommend a higher dose for radio-resistant tumors? Jpn J Clin Oncol 2023; 53:179-181. [PMID: 36373890 DOI: 10.1093/jjco/hyac171] [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: 07/04/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Compared with the European or the United States' uterine cervical cancer management guidelines, which aim to deliver >85 Gy EQD2 (the equivalent effective dose in 2 Gy per fraction) to the high-risk clinical target volume (CTVHR) D90 (minimal dose of 90% of the CTVHR), the dose goal of the corresponding Japanese guidelines does not recommend delivering such a high dose to the CTVHR D90. Subsequently, while the rate of late radiation-induced toxicities is reported to be much lower in the Japanese schedule, the local control rate is relatively inferior to that of clinical results reported by the IntErnational study on MRI-guided BRAchytherapy in CErvical cancer study (EMBRACE-I) in which the dose goal for CTVHR D90 was >85 Gy and showed >90% local control regardless of tumor stage. In daily clinical practice, patients with residual disease supposedly due to insufficient total dose delivery are occasionally referred to our hospital for the possibility of re-irradiation, which is not usually recommended because the risk of late severe radiation-induced toxicity is high. In this report, the authors hope to raise a discussion in our community about modifying our treatment guidelines to recommend a higher dose at least for patients with poor response.
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Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Ayaka Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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