Treatment-Related Radiation Toxicity Among Cervical Cancer Patients

Development and validation of an automated Tomotherapy planning method for cervical cancer

PURPOSE

This study aimed to develop an automated Tomotherapy (TOMO) planning method for cervical cancer treatment, and to validate its feasibility and effectiveness.

MATERIALS AND METHODS

The study enrolled 30 cervical cancer patients treated with TOMO at our center. Utilizing scripting and Python environment within the RayStation (RaySearch Labs, Sweden) treatment planning system (TPS), we developed automated planning methods for TOMO and volumetric modulated arc therapy (VMAT) techniques. The clinical manual TOMO (M-TOMO) plans for the 30 patients were re-optimized using automated planning scripts for both TOMO and VMAT, creating automated TOMO (A-TOMO) and automated VMAT (A-VMAT) plans. We compared A-TOMO with M-TOMO and A-VMAT plans. The primary evaluated relevant dosimetric parameters and treatment plan efficiency were assessed using the two-sided Wilcoxon signed-rank test for statistical analysis, with a P-value < 0.05 indicating statistical significance.

RESULTS

A-TOMO plans maintained similar target dose uniformity compared to M-TOMO plans, with improvements in target conformity and faster dose drop-off outside the target, and demonstrated significant statistical differences (P+ < 0.01). A-TOMO plans also significantly outperformed M-TOMO plans in reducing V50Gy, V40Gy and Dmean for the bladder and rectum, as well as Dmean for the bowel bag, femoral heads, and kidneys (all P+ < 0.05). Additionally, A-TOMO plans demonstrated better consistency in plan quality. Furthermore, the quality of A-TOMO plans was comparable to or superior than A-VMAT plans. In terms of efficiency, A-TOMO significantly reduced the time required for treatment planning to approximately 20 min.

CONCLUSION

We have successfully developed an A-TOMO planning method for cervical cancer. Compared to M-TOMO plans, A-TOMO plans improved target conformity and reduced radiation dose to OARs. Additionally, the quality of A-TOMO plans was on par with or surpasses that of A-VMAT plans. The A-TOMO planning method significantly improved the efficiency of treatment planning.

Comparison of Oncologic Outcomes between Radical Hysterectomy and Primary Concurrent Chemoradiotherapy in Women with Bulky IB and IIA Cervical Cancer under Risk Stratification

PURPOSE

To stratify patients according to tumor marker and histology and compare the survival outcome between radical hysterectomy (RH) and primary concurrent chemoradiotherapy (CCRT) in bulky IB and IIA cervical cancer.

METHODS

A total of 442 patients with cervical cancer were enrolled in the Chang Gung Research Database from January 2002 to December 2017. Patients with squamous cell carcinoma (SCC) and carcinoembryonic antigen (CEA) ≥10 ng/mL, adenocarcinoma (AC), or adenosquamous carcinoma (ASC) were stratified into the high-risk (HR) group. The others were classified into the low-risk (LR) group. We compared oncology outcomes between RH and CCRT in each group.

RESULTS

In the LR group, 5-year overall survival (OS) and recurrence-free survival (RFS) were 85.9% vs. 85.4% (p = 0.315) and 83.6% vs. 82.5% (p = 0.558) in women treated with RH (n = 99) vs. CCRT (n = 179), respectively. In the HR group, the 5-year OS and RFS were 83.2% vs. 73.3% (p = 0.164) and 75.2% vs. 59.6% (p < 0.036) in patients treated with RH (n = 128) vs. CCRT (n = 36), respectively. Regarding recurrence, locoregional recurrence (LRR) (8.1% vs. 8.6%, p = 0.812) and distant metastases (DM) (17.8% vs. 21%, p = 0.609) were similar between RH and CCRT in the LR group. However, lower LRR (11.6% vs. 26.3%, p = 0.023) but equivalent DM (17.8% vs. 21%, p = 0.609) were found for women undergoing RH compared with CCRT in the HR group.

CONCLUSIONS

There were similar survival and recurrence rates between both treatment modalities in low-risk patients. Meanwhile, primary surgery with or without adjuvant radiation provides better RFS and local control in women with high-risk features. Further prospective studies are needed to confirm these findings.

Pelvic floor dysfunction and its influencing factors during radiotherapy in cervical cancer survivors: A cross-sectional study

PURPOSE

Radiotherapy can negatively affect the pelvic floor function of patients with cervical cancer; however, the impact of different radiotherapy times and other related factors on pelvic floor function in cervical cancer survivors during radiotherapy remains unclear. We aimed to investigate the status of pelvic floor dysfunction (PFD) in cervical cancer survivors during radiotherapy and to analyze the factors influencing PFD.

METHODS

In this cross-sectional study, a convenience sampling method was used to recruit cervical cancer survivors undergoing radiotherapy from January 2022 to July 2022 at a tertiary first-class hospital located in northeastern China. The Pelvic Floor Distress Inventory-Short Form 20 was used for participants' self-report of their PFD during radiotherapy.

RESULTS

Data from 120 cervical cancer survivors were included in this study. The results showed that the mean PFDI-20 total score was 32.69 ± 7.76. Multiple stepwise linear regression analysis showed that 56.9% of the variance in PFD was explained by age (β = 0.25, p < 0.001), body mass index (β = 0.32, p < 0.001), recurrence (β = 0.29, p < 0.001), number of radiotherapy sessions (β = 0.39, p < 0.001), and number of deliveries (β = 0.35, p < 0.001).

CONCLUSION

It is important to pay more attention to the PFD status of cervical cancer survivors receiving radiotherapy. Future therapeutic approaches should involve early identification of relevant risk factors early to provide patients with personalized care at different stages of radiotherapy for reducing their discomfort and improving their health-related quality of life.

Effect of Race and Ethnicity on Risk of Radiotherapy Toxicity and Implications for Radiogenomics

AIMS

Patient factors affect the risk of radiotherapy toxicity, but many are poorly defined. Studies have shown that race affects cancer incidence, survival, drug response, molecular pathways and epigenetics. Effects on radiosensitivity and radiotherapy toxicity are not well studied. The aim of the present study was to identify the effects of race and ethnicity on the risk of radiotherapy toxicity.

MATERIALS AND METHODS

A systematic review was carried out of PubMed, Ovid Medline and Ovid Embase with no year limit. PRISMA 2020 guidelines were followed. Two independent assessors reviewed papers.

RESULTS

Of 607 papers screened, 46 fulfilled the inclusion criteria. Papers were published between 1996 and 2021 and involved 30-28,354 individuals (median 433). Most involved patients with prostate (33%), breast (26%) and lung (9%) cancer. Both early and late toxicities were studied. Some studies reported a higher risk of toxicity in White men with prostate cancer compared with other races and ethnicities. For breast cancer patients, some reported an increased risk of toxicity in White women compared with other race and ethnic groups. In general, it was difficult to draw conclusions due to insufficient reporting and analysis of race and ethnicity in published literature.

CONCLUSIONS

Reporting of race and ethnicity in radiotherapy studies must be harmonised and improved and frameworks are needed to improve the quality of reporting. Further research is needed to understand how ancestral heritage might affect radiosensitivity and risk of radiotherapy toxicity.

Distinct mechanism of cervical cancer cell death caused by the investigational new drug SHetA2

Drug-targetable vulnerabilities of cancer cells include their dependence on heat shock proteins (HSPs) to support elevated mitochondrial metabolism and counteract cell death factors. The investigational new drug SHetA2 targets these vulnerabilities in ovarian and endometrial cancer cells by disrupting complexes of the mortalin HSP with its client proteins (mitochondrial support proteins, metabolic enzymes, p53) leading to mitochondrial leakage of cytochrome c and apoptosis-inducing factor (AIF), and caspase-dependent apoptosis. Our objective was to evaluate the roles of mitochondrial damage and another SHetA2-target HSP protein, cytoplasmic heat shock cognate 70 (hsc70), in the mechanism of SHetA2 killing of cervical cancer cells. Cervical cancer cells responded to SHetA2 with excessive mitophagy that did not deter AIF leakage into the cytoplasm. Then, hsc70 was unable to prevent cytoplasmic AIF nuclear translocation and promotion of DNA damage and cell death, because SHetA2 disrupted hsc70/AIF complexes. The Cancer Genome Atlas analysis found that overexpression of hsc70, but not mortalin, was associated with worse cervical cancer patient survival. Use of specific inhibitors documented that AIF and mitophagy, but not caspases, contributed to the mechanism of SHetA2-induced cell death in cervical cancer cells. As validation, excessive mitophagy and lack of caspase activation were observed in SHetA2-inhibited xenograft tumors.

To evaluate the use of tandem and cylinder as an intracavitary brachytherapy device for carcinoma of the cervix with regard to local control and toxicities

Introduction

Brachytherapy always remains a keystone in the treatment of gynecological carcinoma for both definitive and adjuvant treatments. Due to the rapid fall-off nature of brachytherapy, the target gets a high dose with a low dose to the normal organs nearby and thereby increasing the tumor control probability.

Aims and Objectives

This study aims at the evaluation of local control and toxicities in the carcinoma of the cervix using tandem and cylinder as brachytherapy applicator.

Materials and Methods

The study was conducted between January 2014 and December 2018 in a tertiary care hospital. Thirty-one patients who fulfilled our set criterion of Clinical stage IB3-IVA, Performance status Eastern Cooperative Oncology Group 0-2 were selected. All patients were treated initially with external beam radiotherapy and later by high dose rate intracavitary brachytherapy after completion of external beam radiation therapy (EBRT). A dose of 18-21 Gy was delivered to the residual disease in three sessions with a 1-week interval between each session. The dose was optimized in such a way that the organs at risk (OAR), namely bladder and rectum received doses within their tolerance levels. The patients were continuously monitored using Common Terminology Criteria for Adverse Events version 5.0 for both acute and late toxicities and by imaging for local control. Statistical analysis using SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA) was used to evaluate the results. Continuous variables were expressed as mean ± standard deviation, and categorical variables were summarized as frequencies and percentages.

Results

Out of the 31 patients, 5 (16.1%) experienced radiation-induced Grade 1 skin changes which were due to EBRT, 1 (3.2%) had Grade 1 G. I. T toxicity, 1 (3.2%) had Grade 1 radiation-induced vaginal mucositis after brachytherapy. At 6-8-week follow-up, all the patients showed no evidence of disease on radiological imaging. At 3 months of follow-up, 1 (3.2%) patient had radiation-induced proctitis of Grades 2 and 3 (9.7%) had radiation-induced cystitis of Grades 1 and 1 (3.2%) had Grade 2 cystitis. At 6 months of follow-up, 1 (3.2%) had Grade 1, 1 (3.2%) had Grade 2, and 1 (3.2%) had Grade 3 radiation-induced proctitis. At 3 months of follow-up, 29 (93.5%) patients had no evidence of disease, while 2 (6.5%) were having residual disease on imaging. At 6 months of follow-up, all the patients were disease-free. At 12 months of follow-up, 26 (83.9%) patients were disease-free, 1 (3.2%) had local recurrence, 2 (6.5%) had distant metastasis, and 2 (6.5%) had expired. At 24 months of follow-up, 26 patients were disease-free. Acute and late toxicities were similar to those used in the treatment of carcinoma cervix by standard brachytherapy applicators. Local control was achieved in 83.87% of cases. Two-year survival was 93.5%.

Conclusion

We observed that the tandem and cylinder applicator is an acceptable applicator to be used for intracavitary brachytherapy. It is safe and simple besides this; the toxicities and local control are similar to the other standard applicators used in brachytherapy in carcinoma cervix. However, the required dose prescription to point A was not possible in all the patients due to limitations of OARs. Furthermore, long-term follow-up is needed to see the patterns of failure, recurrence-free survival, overall survival, and long-term toxicities in the treated patients.

Handgrip Strength, Overhydration and Nutritional Status as a Predictors of Gastrointestinal Toxicity in Cervical Cancer Patients. A Prospective Study

Background: Antineoplastic treatments produce adverse events (AE) such as gastrointestinal toxicity. These AE can reduce nutritional intake and promote weight and muscle mass loss. Objective: To determine if body composition, nutritional status, or muscle function predicts gastrointestinal toxicity during chemotherapy in cervical cancer (CC) patients. Methods: Women with CC were studied. Nutritional status was evaluated according to PG-SGA, and body composition was measured with bioimpedance. Toxicity was graded according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE). Results: A total of 207 women, 81 with toxicity and 126 without toxicity groups, were studied. Patients in the toxicity group had less handgrip strength (17.7 ± 5.0 vs. 20.3 ± 5.0 p = 0.0004); phase angle (5.2 ± 1.1 vs. 5.9 ± 1.0, p = 0.0065); higher prevalence of sarcopenia (35.9% vs. 20.6%, p = 0.016); overhydration (25.9% vs. 6.3% p < 0.001); and PG-SGA C (14.1% vs. 4.0%, p < 0.001) when compared to patients without toxicity. Handgrip strength (HR: 0.93, 95% CI 0.88-0.98, p = 0.028), overhydration (HR: 2.82, 95% CI 1.22-6.51, p = 0.015) and been severely malnourished according to PG-PGA (HR: 3.6, 95%CI 1.46-9.2, p < 0.001) were associated with the risk to present gastrointestinal toxicity. Conclusion: handgrip strength, overhydration, and severe malnutrition are independent risk factors to the presence of gastrointestinal toxicity in CC patients.

High dose rate192Ir versus high dose rate60Co brachytherapy: an overview of systematic reviews of clinical responses of gynecological cancers from 1984 to 2020

The Purpose. Radioisotope of192Iradium (192Ir) has a half-life (74 days) and is not easily accessible in developing countries. As a result, by the time source shipment clearance and the customs paperwork are completed, a large proportion of useful activity had already been decayed away. In fact,60Cobalt (60Co) remote afterloading systems are commercially available by many venders. As a result, it may well become an alternative source to192Ir and conform many of these challenges. The aim of this study is that to report clinical responses of different types of gynaecological cancers treated with high dose rate (HDR)192Ir and HDR60Co brachytherapy in order to check whether HDR60Co could be used as an alternative brachytherapy, source to HDR192Ir.Materials and Methods. A retrospective study of clinical responses of different types of gynaecological cancers, staged from I to IV according to recommendations of International Federation of Gynaecology and Obstetrics (FIGO), treated by brachytherapy alone, radiotherapy alone (combined brachytherapy and radiotherapy) and combined radiotherapy and chemotherapy (brachytherapy, radiotherapy and chemotherapy) between 1984 and December 2020 was conducted. The patients were treated with external beam radiotherapy 45-51 Gy boosted with HDR192Ir and HDR60Co afterloading brachytherapy of 18-30 Gy to point A.The results. The study scrutinized the data of 11086 patients with different types of gynaecological cancers. Most of the patients, 70 percent of them, were diagnosed with gynaecological cancers in stages II and III. For patients treated with192Ir brachytherapy source 5-years overall survival rate (OS), local control, 2-years, 5-years and 10-years disease free survival (DFS), complications of gastro-intestine (GI) and complications of genito-urinary (GU) were 63.5%, 92%, 72.6%, 64.07%, 43.75%, 3.9% and 5.92%, but for those treated with60Co they were 57.7%, 86.63%, 82.5%, 53.35%, 43.75%, 4.8% and 3.7%, respectively.Conclusions.The use of HDR60Co brachytherapy has the capacity to produce overall survival rate and disease control in patients with carcinoma of the gynaecology comparable to that reported for HDR192Ir brachytherapy. Currently, the toxicity and damage of the normal tissues and radiation-related second cancers are of a similar incidence to that of standard HDR192Ir brachytherapy. Source exchange frequency is not a serious concern because it requires less frequency of replacement, and commissioning can be accomplished within years; hence, replacing HDR192Ir with HDR60Co brachytherapy achieves significant cost saving. Therefore, we recommend that60Co source ought to be the first choice for low resource radiotherapy setting as it offers economic advantages over192Ir and have comparable clinical outcomes to that of192Ir source.