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Mu Y, Wang H, Xu L, Shi L, Song R, Wang D, Gao Y, Yan H. Analysis of the therapeutic effect of synchronous integrated intensity modulated radiotherapy combined with chemotherapy in stage IIIc of cervical cancer. Front Oncol 2024; 14:1283991. [PMID: 38884092 PMCID: PMC11177616 DOI: 10.3389/fonc.2024.1283991] [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: 08/31/2023] [Accepted: 05/09/2024] [Indexed: 06/18/2024] Open
Abstract
Objective To explore the Therapeutic effect of synchronous Integrated intensity modulated radiotherapy combined with chemotherapy in stage IIIc of Cervical Cancer. Methods A total of 58 patients with stage IIIC cervical cancer (KPS ≥ 80) were analyzed in this study. They were admitted to our hospital between August 2017 and August 2022. Synchronous integrated boost intensity-modulated radiotherapy (SIB-IMRT) and sequential boost intensity-modulated radiotherapy (LCB-IMRT) were used to treat pelvic and/or para-aortic metastatic lymph nodes, with 30 cases in the SIB group and 28 cases in the LCB group. Comparison of short-term and long-term efficacy. Comparison of recurrence and metastasis rates, radiation dose to organs at risk and incidence of adverse drug reactions. Result 30 patients were treated with simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT), and 28 patients were treated with sequential boost intensity-modulated radiotherapy (LCB-IMRT). At the completion of radiotherapy and 3 months after radiotherapy, there was no significant difference in clinical efficacy observed between the two treatment groups. The median overall survival (OS), progression-free survival (PFS), and disease-free survival (DMR) in the SIB-IMRT group were significantly higher compared to the LCB-IMRT group. The SIB-IMRT group demonstrated significantly lower rates compared to the LCB-IMRT group. Furthermore, within 3 years and 5 years, the rates of lymph node recurrence, cervical and vaginal local recurrence, and distant metastasis within the radiotherapy field were significantly lower in the SIB-IMRT group compared to the LCB-IMRT group. There were no significant differences observed between the two groups in terms of the maximum dose to the small intestine (Dmax), dose received by 2cc of the small intestine (D2cc), maximum dose to the rectum (Dmax), and dose received by 1cc of the bladder (D1cc). The incidence of bone marrow toxicity in the SIB-IMRT group was significantly lower compared to the LCB-IMRT group. Moreover, the occurrence of grade III and IV bone marrow toxicity was also significantly lower in the SIB-IMRT group compared to the LCB-IMRT group. Conclusion The study has concluded that there is no significant differences in in terms of bladder associated adverse events and gastrointestinal toxicity in both Simultaneous Integrated Boost Intensity-Modulated Radiotherapy and Layered Conical Beam Intensity-Modulated Radiation Therapy.
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Affiliation(s)
- Yanru Mu
- Radiotherapy Department, Liaoning Health Industry Group Bengang General Hospital, Benxi, Liaoning, China
| | - Hui Wang
- Radiotherapy Department, Liaoning Health Industry Group Bengang General Hospital, Benxi, Liaoning, China
| | - Li Xu
- Radiotherapy Department, Liaoning Health Industry Group Bengang General Hospital, Benxi, Liaoning, China
| | - Li Shi
- Gynaecology and Obstetrics, Liaoning Health Industry Group Bengang General Hospital, Benxi, Liaoning, China
| | - Rui Song
- Gynaecology and Obstetrics, Liaoning Health Industry Group Bengang General Hospital, Benxi, Liaoning, China
| | - Dezhi Wang
- Medical Imaging Department, Liaoning Health Industry Group Bengang General Hospital, Benxi, Liaoning, China
| | - Yuhua Gao
- Gynecology and Oncology Department, Liaoning Cancer Institute and Hospital, Shenyang, Liaoning, China
- Nuclear Medicine, Benxi Central Hospital, Benxi, Liaoning, China
| | - Haibo Yan
- Gynecology and Oncology Department, Liaoning Cancer Institute and Hospital, Shenyang, Liaoning, China
- Nuclear Medicine, Benxi Central Hospital, Benxi, Liaoning, China
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Hsieh K, Bloom JR, Dickstein DR, Hsieh C, Marshall D, Ghiassi-Nejad Z, Raince J, Lymberis S, Chadha M, Gupta V. Dose and fractionation regimen for brachytherapy boost in cervical cancer in the US. Gynecol Oncol 2024; 180:55-62. [PMID: 38052109 DOI: 10.1016/j.ygyno.2023.11.014] [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: 08/28/2023] [Revised: 11/06/2023] [Accepted: 11/12/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics. METHODS We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018-2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise. RESULTS Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184). CONCLUSIONS In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes.
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Affiliation(s)
- Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Julie R Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Celina Hsieh
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Deborah Marshall
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Zahra Ghiassi-Nejad
- Department of Radiation Oncology, Columbia University Medical Center, New York, NY, United States of America
| | - Jagdeep Raince
- Department of Radiation Oncology, New York University Langone Health, New York, NY, United States of America
| | - Stella Lymberis
- Department of Radiation Oncology, New York University Langone Health, New York, NY, United States of America
| | - Manjeet Chadha
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Vishal Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Kibret YM, Tigeneh W, Jemal A, Kantelhardt EJ. Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report. JCO Glob Oncol 2023; 9:e2200407. [PMID: 37595167 PMCID: PMC10581656 DOI: 10.1200/go.22.00407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 08/20/2023] Open
Abstract
PURPOSE Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia. MATERIALS AND METHODS A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period. RESULTS During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib-IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients. CONCLUSION The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.
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Affiliation(s)
- Yitbarek M. Kibret
- Oncology Department, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
- Global Health Working Group, Martin-Luther-University Halle-Wittenberg, Germany
| | | | - Ahmedin Jemal
- Surveillance and Health Service Research, American Cancer Society, Atlanta, GA
| | - Eva J. Kantelhardt
- Global Health Working Group, Martin-Luther-University Halle-Wittenberg, Germany
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Ma CY, Zhao J, Gan GH, He XL, Xu XT, Qin SB, Wang LL, Li L, Zhou JY. Establishment of a prediction model for severe acute radiation enteritis associated with cervical cancer radiotherapy. World J Gastroenterol 2023; 29:1344-1358. [PMID: 36925455 PMCID: PMC10011961 DOI: 10.3748/wjg.v29.i8.1344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Cervical cancer is one of the most common gynecological malignant tumors. Radiation enteritis (RE) leads to radiotherapy intolerance or termination of radiotherapy, which negatively impacts the therapeutic effect and seriously affects the quality of life of patients. If the incidence of RE in patients can be predicted in advance, and targeted clinical preventive treatment can be carried out, the side effects of radiotherapy in cervical cancer patients can be significantly reduced. Furthermore, accurate prediction of RE is essential for the selection of individualized radiation dose and the optimization of the radiotherapy plan.
AIM To analyze the relationships between severe acute RE (SARE) of cervical cancer radiotherapy and clinical factors and dose-volume parameters retrospectively.
METHODS We included 50 cervical cancer patients who received volumetric modulated arc therapy (VMAT) from September 2017 to June 2018 in the Department of Radiotherapy at The First Affiliated Hospital Soochow University. Clinical and dose-volume histogram factors of patients were collected. Logistic regression analysis was used to evaluate the predictive value of each factor for SARE. A nomogram to predict SARE was developed (SARE scoring system ≥ 3 points) based on the multiple regression coefficients; validity was verified by an internal verification method.
RESULTS Gastrointestinal and hematological toxicity of cervical cancer VMAT gradually increased with radiotherapy and reached the peak at the end of radiotherapy. The main adverse reactions were diarrhea, abdominal pain, colitis, anal swelling, and blood in the stool. There was no significant difference in the incidence of gastrointestinal toxicity between the radical and postoperative adjuvant radiotherapy groups (P > 0.05). There were significant differences in the small intestine V20, V30, V40, and rectal V40 between adjuvant radiotherapy and radical radiotherapy after surgery (P < 0.05). Univariate and multivariate analyses revealed anal bulge rating (OR: 14.779, 95%CI: 1.281-170.547, P = 0.031) and disease activity index (DAI) score (OR: 53.928, 95%CI: 3.822-760.948, P = 0.003) as independent predictors of SARE.
CONCLUSION Anal bulge rating (> 0.500 grade) and DAI score (> 2.165 points) can predict SARE. The nomogram shows potential value in clinical practice.
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Affiliation(s)
- Chen-Ying Ma
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Jing Zhao
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Guang-Hui Gan
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Xiao-Lan He
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Xiao-Ting Xu
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Song-Bing Qin
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Li-Li Wang
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Li Li
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Ju-Ying Zhou
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou 215123, Jiangsu Province, China
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Pretreatment Radiologically Enlarged Lymph Nodes as a Significant Prognostic Factor in Clinical Stage IIB Cervical Cancer: Evidence from a Taiwanese Tertiary Care Center in Reaching Consensus. Diagnostics (Basel) 2022; 12:diagnostics12051230. [PMID: 35626385 PMCID: PMC9140083 DOI: 10.3390/diagnostics12051230] [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: 05/02/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 12/02/2022] Open
Abstract
The incidence of lymph node (LN) involvement and its prognostic value based on radiological imaging in stage IIB cervical cancer (CC) remains unclear, and evidence regarding oncological outcomes of patients with stage IIB CC with LN metastases is limited. In this study we retrospectively reviewed the incidence and prognostic significance of pretreatment radiologic LN status in 72 patients with clinical stage IIB CC (FIGO 2009), with or without radiologic evidence of LN enlargement. An enlarged LN was defined as a diameter > 10 mm on CT/MRI. Progression-free survival (PFS) and overall survival (OS) were assessed. Radiologic LN enlargement of >10 mm was observed in 45.8% of patients with stage IIB CC. PFS (p = 0.0088) and OS rates (p = 0.0032) were significantly poorer in the LN group (n = 33) than in the non-LN group (n = 39). Univariate Cox analysis revealed that LN > 10 mm contributed to a higher rate of recurrence and mortality. In conclusion, nearly half of the patients with clinical stage IIB CC had enlarged LNs (>10 mm) identified during pretreatment radiologic evaluation, which negatively impacted prognosis. Our findings highlight the need to incorporate CT- or MRI-based LN assessment before treatment for stage IIB CC.
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Intracavitary Brachytherapy from 2D to 3D. Brachytherapy 2019. [DOI: 10.1007/978-981-13-0490-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bandyopadhyay A, Basu P, Roy K, Das S, Banerjee S. Treatment of locally advanced carcinoma cervix with special emphasis on brachytherapy: A practice pattern survey among young radiation oncologist of India. South Asian J Cancer 2018; 7:231-235. [PMID: 30430090 PMCID: PMC6190401 DOI: 10.4103/sajc.sajc_198_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Carcinoma cervix is one of the two most common cancers of Indian women with very high morbidity and mortality burden. Although India probably is the leading country in numbers patients of cervix treated radically with combination of teletherapy and brachytherapy (BT), there is presumed diversity of practice across the country due to the inequality of available infrastructure, absence of uniform the training of the radiation oncologists, and absence of any national guidelines. The present survey was conducted to determine current practice patterns in management of locally advanced carcinoma cervix with regard to gynecologic high-dose-rate among the radiation oncologist across the country. METHODOLOGY A 25-item survey was undertaken to study the standard management pattern of Stage IIB-IIIB cervical cancer with special emphasis on the BT practice patterns among various young radiation oncologist working across the country. The survey was undertaken in person in the form of interview questionnaire among the younger members of association of radiation oncologist of India during two national conferences, along with telephonic interview of other members as obtained from the national directory. RESULTS About 57 young radiation oncologists from 57 centers across the country were surveyed. 25 of them represented private nonacademic centers, 24 represented government academic centers, the rest were from private academic, nongovernmental organization (NGO) run and other centers. The most common teletherapy dose prescribed was 46 Gy/23# for Stage II, and50 Gy/25 # for Stage III disease. HDR after loader with 192Ir is the most common machine (82.6%) in use and computed tomography scan is the most commonly (30/57) used imaging for planning. The most common intracavitary dose pattern for all stages was 7 Gy × 3 fractions (30/57s) and 9 Gy × 2 (12/57) fractions. Although in most centers, computed tomography-based delineation of organs at risk is done routinely; however, target volume delineation and dose prescription/optimization for the same is routinely done in handful of centers (5/57). The mean planned dose to Point A for combined external-beam radiation and BT (EQD210) was about 77.5 Gy for Stage IIIB and 72.6 Gy for Stage II disease. CONCLUSION Although fractionation patterns may vary, the overall mean dose administered for cervical cancer is similar across the country, which is slightly lower than the recommended doses as per stage by various international guidelines.
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Affiliation(s)
- Anis Bandyopadhyay
- Department of Radiotherapy, Medical College Kolkata, Kolkata, West Bengal, India
| | - Poulami Basu
- Department of Radiotherapy, Medical College Kolkata, Kolkata, West Bengal, India
| | - Kaushik Roy
- Department of Radiotherapy, Medical College Kolkata, Kolkata, West Bengal, India
| | - Suman Das
- Department of Radiations Oncology, Queen's NRI Hospital, Vishakapatnam, Andhra Pradesh, India
| | - Susovan Banerjee
- Department of Radiation Oncology, Medanta The Medicity, Gurgaon, Haryana, India
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Lee HJ, Kim YS, Shin SS, Nam JH, Kim YT, Han S, Choi EK. Long-Term Outcomes of Concomitant Chemoradiotherapy Incorporating High-Dose-Rate Brachytherapy to Treat Locally Advanced Cervical Cancer. TUMORI JOURNAL 2018; 98:615-21. [DOI: 10.1177/030089161209800512] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim and background We reviewed the long-term clinical outcomes of patients treated with cisplatin-based concurrent chemoradiotherapy (CCRT) incorporating high-dose-rate (HDR) intracavitary brachytherapy (ICBT) in terms of toxicity, local control and survival rates. In addition, we identified prognostic factors for overall and disease-free survival. Methods and study design Two hundred and nine patients with stage IB2-IVA cervical cancer underwent curative cisplatin-based CCRT plus HDR ICBT. Women with stage IB2-IIB disease were given 41.4 Gy of external radiotherapy followed by 35 Gy (in 7 fractions) of ICBT. Women with stage IIIA-IVA were given 50.4 Gy followed by 30 Gy (in 6 fractions) of ICBT. Patients with parametrial disease or pelvic lymphadenopathy were given parametrial boosts via external beam radiation at a dose of up to 65 Gy to thickened and 60 Gy to unthickened parametrial regions. Results One hundred and thirty (62%) patients experienced acute grade 3-4 hematological toxicities and 11 (5%) patients had late grade 3 gastrointestinal or genitourinary complications. Complete responses occurred in 168 (80%) women as determined by clinical and imaging studies. The median follow-up period was 52 months for surviving patients and the 5-year overall and disease-free survival rates were 74% and 67%, respectively. Multivariate analysis indicated that tumor size and paraaortic lymph node involvement were prognostically significant in terms of overall survival, and that tumor diameter was a significant prognostic factor and pelvic lymph node status a marginally significant prognostic factor for disease-free survival. Conclusions Patients treated with our current HDR ICBT protocol have acceptably low late complication rates and local control and survival rates comparable to those reported in other studies. Tumor diameter was an important prognostic factor in terms of both overall and disease-free survival, emphasizing the need for modern ICBT methodologies.
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Affiliation(s)
- Hyun Jin Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Seong Soo Shin
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Joo-Hyun Nam
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Young-Tak Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Seungbong Han
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
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Appropriate magnetic resonance imaging techniques for gross tumor volume delineation in external beam radiation therapy of locally advanced cervical cancer. Oncotarget 2018. [PMID: 29515794 PMCID: PMC5839375 DOI: 10.18632/oncotarget.24071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Accurate delineation of the gross tumor volumes (GTV) is a prerequisite for precise radiotherapy planning and delivery. Different MRI sequences have different advantages and limitations in their ability to discriminate primary cervical tumor from normal tissue. The purpose of this work is to determine appropriate MRI techniques for GTV delineation for external-beam radiation therapy of locally advanced cervical cancer (LACC). Materials and Methods GTVs were delineated on the MRI, CT, and PET images acquired for 23 LACC patients in treatment positions to obtain GTVs on CT (GTV-CT), on various MRI sequences including T1 (GTV-T1), T2 (GTV-T2), T1 with fat suppression and contrast (GTV-T1F+), DWI-ADC (GTV-ADC) and on PET were generated using the threshold of 40% of maximum SUV (GTV-SUV40%) as well as SUV of 2.5 (GTV-SUV2.5). MRI, CT and PET were registered for comparison. The GTVs defined by MRI were compared using the overlap ratio (OR) and relative volume ratio (RVR). The union of GTV-T2 and GTV-ADC was generated to represent the MRI-based GTV (GTV-MRI). Results The differences between GTV-T2 and other MRI GTVs are significant (P < 0.05). The average ORs for GTV-T1, GTV-T1F+, and GTV-ADC related to GTV-T2 were 86.3%, 81.6%, and 61.6% with the corresponding average RVRs 113.8%, 112.3% and 77.2%, respectively. There is no significant difference between GTV-T1 and GTV-T1F+. GTV-ADC was generally smaller than GTV-T2, however, encompassed suspicious regions that are uncovered in GTV-T2 (up to 16% of GTV-T2) because of different imaging mechanisms. There was significant difference between GTV-MRI, GTV-SUV2.5, GTV-SUV40%, and GTV-CT. On average, GTV-MRI is 18.4% smaller than GTV-CT. Conclusions MRI provides improved visualization of disease over CT or PET for cervical cancer. The GTV from the union of GTV-T2 and GTV-ADC provides a reasonable GTV including tumor region defined anatomically and functionally with MRI and substantially reduces the conventional GTV defined on CT.
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Shiba S, Wakatsuki M, Kato S, Ohno T, Okonogi N, Karasawa K, Kiyohara H, Tsujii H, Nakano T, Kamada T, Shozu M. Carbon-ion radiotherapy for locally advanced cervical cancer with bladder invasion. JOURNAL OF RADIATION RESEARCH 2016; 57:684-690. [PMID: 27422932 PMCID: PMC5137292 DOI: 10.1093/jrr/rrw070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/28/2016] [Accepted: 05/18/2016] [Indexed: 06/06/2023]
Abstract
The purpose of this study was to evaluate the efficacy and toxicities of carbon-ion radiotherapy (C-ion RT) for locally advanced cervical cancer with bladder invasion by a subset analysis of pooled data from eight prospective clinical trials at the National Institute of Radiological Sciences. Between June 1995 and January 2014, 29 patients with locally advanced cervical cancer with bladder invasion were identified. The median age was 56 years old (range 31-79 years old). The median tumor size at diagnosis on magnetic resonance imaging was 6.7 cm (range 3.5-11.0 cm). Histologically, 20 patients had squamous cell carcinoma and 9 had adenocarcinoma. C-ion RT was performed as a dose-escalation study in the initial trials. All patients received prophylactic whole-pelvic or extended-field irradiation and local boost. The total dose to the cervical tumor was 52.8-74.4 Gy (relative biological effectiveness) in 20 or 24 fractions. Weekly cisplatin (40 mg/m2/week, five cycles) was concurrently given to four patients. The median follow-up of all patients was 28.6 months (range 8.8-238.6 months). Grade 2 or higher late complications in the bladder were observed in eight patients, with seven developing vesicovaginal fistula. Six patients had Grade 2 or higher complications in the rectosigmoid colon. The 3-year overall survival rate was 47%, the 3-year local control rate was 66%, and the 3-year disease-free survival rate was 28%. In this study, C-ion RT showed favorable local control with reasonable toxicities, but the results were still unsatisfactory. We have the expectation of improvement of therapeutic effects by using C-ion RT with concurrent chemotherapy.
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Affiliation(s)
- Shintaro Shiba
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
- National Institutes for Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba-city, Chiba 263-8555, Japan
| | - Masaru Wakatsuki
- National Institutes for Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba-city, Chiba 263-8555, Japan
- Department of Radiology, Jichi Medical University, 3311-1, Yakushiji, Simotsuke-city, Tochigi 329-0498, Japan
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Noriyuki Okonogi
- National Institutes for Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba-city, Chiba 263-8555, Japan
| | - Kumiko Karasawa
- Department of Radiation Oncology, Tokyo Women's Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Hiroki Kiyohara
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Hirohiko Tsujii
- National Institutes for Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba-city, Chiba 263-8555, Japan
| | - Takashi Nakano
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tadashi Kamada
- National Institutes for Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba-city, Chiba 263-8555, Japan
| | - Makio Shozu
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohara Chuo-ku, Chiba 260-8670, Japan
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11
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Huang EY, Lin H, Wang CJ, Chanchien CC, Ou YC. Impact of treatment time-related factors on prognoses and radiation proctitis after definitive chemoradiotherapy for cervical cancer. Cancer Med 2016; 5:2205-12. [PMID: 27416796 PMCID: PMC5055176 DOI: 10.1002/cam4.794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/15/2016] [Accepted: 05/16/2016] [Indexed: 12/22/2022] Open
Abstract
This study aimed to investigate the impact of treatment time-related factors on outcomes and radiation proctitis in patients undergoing concurrent chemoradiotherapy (CCRT) for cervical cancer. From September 2001 to December 2012, 146 patients with stage IIB cervical squamous cell carcinoma treated with CCRT were reviewed from a prospective cohort. Patients who received the same dose (45 Gy) of external beam radiation therapy (EBRT) were included in the analysis (n = 125). The same equivalent dose of 2 Gy (EQD2) of high-dose-rate intracavitary brachytherapy (HDR-ICBT) was delivered at either 4 fractions of 6 Gy or 6 fractions of 4.5 Gy. The effects of the overall treatment time (OTT) and interval between EBRT and HDR-ICBT on the cancer-specific survival (CSS), local recurrence (LR), and incidence of proctitis were compared. The treatment time-related factors did not adversely affect the CSS and LR rates. The multivariate analyses did not identify the OTT as an independent factor of CSS (P = 0.839) and LR (P = 0.856). However, OTT ≤56 days (P = 0.026) was identified as the only independent factor of overall proctitis. The 5-year Grade 2 or greater proctitis rates were 14.9% and 0% (P = 0.001) in patients with the EBRT to ICBT interval ≤5 days and >5 days, respectively. To reduce rectal damage without compromising prognosis, the gap between EBRT and HDR-ICBT should exceed 5 days in cervical cancer patients undergoing CCRT. Strictly limiting the OTT to 56 days may result in radiation proctitis without improvements in prognosis.
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Affiliation(s)
- Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chong-Jong Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chan-Chao Chanchien
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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12
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Eminowicz G, Rompokos V, Stacey C, McCormack M. The dosimetric impact of target volume delineation variation for cervical cancer radiotherapy. Radiother Oncol 2016; 120:493-499. [PMID: 27162158 DOI: 10.1016/j.radonc.2016.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/18/2016] [Accepted: 04/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cervical cancer inter-observer delineation variation has been demonstrated. This article addresses its dosimetric impact. METHODS 21 centres outlined two INTERLACE trial quality assurance test cases. A gold standard clinical target volume (GSCTV) was created from a consensus and STAPLE outline. RapidArc plans were created for all centres' planning target volumes (PTVs; PTV1+2). Gold standard PTVs (GSPTVs) were created for each plan by applying each centre's CTV-PTV margins to GSCTV. DVH parameters including D95% and Dmean for each PTV1+2 and GSPTV were compared, representing planned versus GSPTV delivered dose. PTV1+2 and GSPTV V95% was also calculated. RESULTS Reviewing all parameters, no plans achieved acceptable GSPTV coverage. GSPTV V95%⩾95% was not achieved for any plan. GSPTV V95%<90% in 15/21 (case 1) and 14/22 (case 2) and <80% in 2 plans from both cases. GSPTV V95% is on average 10-15% lower than planned and GSPTV D95% is 10-20% lower than planned. Most common GSCTV anatomical areas not receiving 95% dose were vagina, obturator and external iliac nodes and, in case 1, the superior nodal aspect. CONCLUSION Cervical cancer CTV delineation variation leads to significant reductions in dose delivered to GSPTV. This highlights the ongoing importance of standardising delineation in the IMRT era.
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Affiliation(s)
- Gemma Eminowicz
- Radiotherapy Department, University College London Hospital, United Kingdom
| | - Vasilis Rompokos
- Radiotherapy Department, University College London Hospital, United Kingdom
| | - Christopher Stacey
- Radiotherapy Department, University College London Hospital, United Kingdom
| | - Mary McCormack
- Radiotherapy Department, University College London Hospital, United Kingdom
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13
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Koulis TA, Doll CM, Brown D, Traptow L, Bhayana D, Nelson G, Phan T. Implementation and validation of a combined MRI-CT–based cervical cancer brachytherapy program using existing infrastructure. Brachytherapy 2016; 15:319-326. [DOI: 10.1016/j.brachy.2016.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 01/26/2016] [Accepted: 01/31/2016] [Indexed: 01/23/2023]
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14
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Fan Q, Yeung AR, Amdur R, Helmig R, Park J, Li J, Kahler D, Liu C, Lu B. Image-Guided High-Dose Rate Brachytherapy in Cervix Carcinoma Using Balloon Catheter and Belt Immobilization System. Technol Cancer Res Treat 2016; 16:257-266. [PMID: 26868850 DOI: 10.1177/1533034616631122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The efficacy of image-guided high-dose rate brachytherapy for cervical cancer is limited by the ineffective rectal sparing devices available commercially and the potential applicator movement. We developed a novel device using a balloon catheter and a belt immobilization system, serving for rectal dose reduction and applicator immobilization purposes, respectively. METHODS The balloon catheter is constructed by gluing a short inflatable tube to a long regular open-end catheter. Contrast agent (10) cm3 is injected into the inflatable end, which is affixed to the tandem and ring applicator, to displace the posterior vaginal wall. The belt immobilization system consists of a specially designed bracket that can hold and fix itself to the applicator, a diaper-like Velcro fastener package used for connecting the patient's pelvis to the bracket, and a buckle that holds the fasteners to stabilize the whole system. The treatment data for 21 patients with cervical cancer using both balloon catheter and belt immobilization system were retrospectively analyzed. Computed tomography and magnetic resonance images, acquired about 30 minutes apart, were registered to evaluate the effectiveness of the immobilization system. RESULTS In comparison with a virtual rectal blade, the balloon decreased the rectal point dose by 34% ± 4.2% (from 276 ± 57 to 182 ± 38 cGy), corresponding to an extra sparing distance of 7.9 ± 1.1 mm. The maximum sparing distance variation per patient is 1.4 ± 0.6 mm, indicating the high interfractional reproducibility for rectum sparing. With the immobilization system, the mean translational and rotational displacements of the applicator set are <3 mm and <1.5°, respectively, in all directions. CONCLUSIONS The rectal balloon provides significant dose reduction to the rectum and it may potentially minimize patient discomfort. The immobilization system permits almost no movement of the applicator during treatment. This work has the potential to be promoted as a standardized solution for high-dose rate treatment of cervical cancer.
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Affiliation(s)
- Qiyong Fan
- 1 Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA.,2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Anamaria R Yeung
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Robert Amdur
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Richard Helmig
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Justin Park
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan Li
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Darren Kahler
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Chihray Liu
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Bo Lu
- 2 Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
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Phan T, Mula-Hussain L, Pavamani S, Pearce A, D'Souza D, Patil NG, Traptow L, Doll CM. The changing landscape of brachytherapy for cervical cancer: a Canadian practice survey. ACTA ACUST UNITED AC 2015; 22:356-60. [PMID: 26628868 DOI: 10.3747/co.22.2562] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We documented changes in practice from 2009 to 2012 for cervical cancer brachytherapy in Canada. METHODS Centres with gynecologic brachytherapy services were sent an e-mail questionnaire querying their 2012 practice. Responses are reported and compared with practice patterns identified in a similar survey for 2009. RESULTS The response rate was 77% (24 of 31 centres). Almost all use high-dose-rate brachytherapy (92%); low-dose-rate brachytherapy has been completely phased out. Most continue to move patients from the site of applicator insertion to the radiation treatment simulation suite (75%) or to a diagnostic imaging department (29%), or both. In 2012, the imaging modalities used for dose specification were computed tomography [ct (75%)], magnetic resonance imaging [mri (38%)], plain radiography (21%), and cone-beam ct (8%). The number of institutions using mri guidance has markedly increased during the period of interest (9 vs. 1). Most respondents (58% vs. 14%) prescribed using guidelines from the Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology and Oncology, but they also used point A as a reference. Commonly used high-dose radiation regimens included 30 Gy in 5 fractions and 24 Gy in 3 fractions. CONCLUSIONS In Canada, image-guided brachytherapy for cervical cancer continues to evolve. Although ct-based imaging remains the most commonly used modality, many centres have adopted mri for at least 1 brachytherapy treatment. More centres are using fewer fractions and a slightly lower biologically effective dose, but are still achieving EQD2 (2-Gy equivalent) doses of 80-90 Gy in combination with external-beam radiation therapy.
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Affiliation(s)
- T Phan
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - L Mula-Hussain
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - S Pavamani
- Department of Radiation Oncology, Christian Medical College, Vellore, South India
| | - A Pearce
- Department of Radiation Oncology, Northeast Cancer Centre, Sudbury, ON
| | - D D'Souza
- Department of Radiation Oncology, London Regional Cancer Program, London, ON
| | - N G Patil
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Halifax, NS
| | - L Traptow
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - C M Doll
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
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Royal-Preyra B, Bowes D, Bahl G, Joseph P, Nolan M, Ymeri H, Bentley J, Patil N. Long-term Outcomes and Late Effects of Definitive Chemoradiotherapy in Patients with Cervical Cancer in Nova Scotia. Cureus 2015; 7:e343. [PMID: 26623198 PMCID: PMC4641723 DOI: 10.7759/cureus.343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: To determine the long-term oncologic outcomes and toxicity of patients treated with definitive chemo-radiotherapy for cervical cancer. Methods and Materials: The study period was January 1, 2000 to December 31, 2009. All patients diagnosed with cervical cancer who received curative-intent chemoradiotherapy were included. Patients were excluded if they resided out of the province, received surgery as an initial treatment, or were treated with palliative intent. A retrospective chart review was performed. Results: Four hundred and eighty-six patients were diagnosed with cervical cancer; 190 met eligibility criteria. Median follow-up for all patients was 3.2 years (interquartile range 1.1—5.6 years). Clinical stage was FIGO IIB or higher in 139 of 190 patients (73.2%). One hundred and fifty-eight (82.7%) received concurrent cisplatin chemotherapy (mean # cycles = 4.8). The most common external beam radiotherapy (EBRT) dose/fractionation schedule was 45 Gray (Gy) in 25 fractions (149 pts, 78.0%). One hundred and thirty-six (71.2%) received low-dose-rate (LDR) brachytherapy (BT: most common dose = 35 Gy). High-dose-rate (HDR) BT was implemented in 2008; the most common HDR dose was 24 Gy in 8 fractions over five days. Five-year overall survival (OS) and progression-free survival (PFS) were 69.4% and 61.4%, respectively. OS and PFS were significantly higher in patients who received chemotherapy vs. radiotherapy alone. For those receiving HDR-BT, there was a significantly higher OS, but not PFS. The rate of late RTOG Grade 3/4 toxicity at five years was 23.3% (gastrointestinal - 26 events, 13% of patients; genitourinary - 13 events, 8% of patients). Fourteen patients had Grade 3 radiation proctitis as the only late toxicity. EBRT dose above 45 Gy was the only factor associated with late toxicity on multivariate analysis. Conclusion: Outcomes of patients treated with chemoradiotherapy for cervical cancer are in keeping with those reported in other series. Chemotherapy improved OS and PFS. External beam radiotherapy dose above 45 Gy was the only predictor of late toxicity.
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Affiliation(s)
| | - David Bowes
- Department of Radiation Oncology, Dalhousie University
| | - Gaurav Bahl
- Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia
| | - Paul Joseph
- Department of Radiation Oncology, Dalhousie University
| | - Maureen Nolan
- Department of Radiation Oncology, Dalhousie University
| | - Hylkije Ymeri
- Department of Radiation Oncology, Dalhousie University
| | - James Bentley
- Division of Gynecology Oncology, Dalhousie University
| | - Nikhilesh Patil
- Nova Scotia Cancer Centre, Nova Scotia Health Authority, Dalhousie University
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Long Follow-up of Patients With Locally Advanced Cervical Cancer Treated With Concomitant Chemobrachyradiotherapy With Cisplatin and Ifosfamide Followed by Consolidation Chemotherapy. Int J Gynecol Cancer 2015; 25:315-9. [DOI: 10.1097/igc.0000000000000336] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectivesLocally advanced cervical cancer (LACC) is one of the leading health problems of the developing countries. We present long-term outcomes of treatment with a concomitant chemobrachyradiotherapy followed by consolidation chemotherapy regimen.Materials and MethodsWe treated 118 patients with LACC (International Federation of Gynecology and Obstetrics stages IB2-IVA) with external radiotherapy (50 Gy in 25 fractions) and concomitant chemobrachyradiotherapy (low-dose rate). Chemotherapy was applied during brachyradiotherapy (cisplatin on day 1 in combination with 24-hour infusion of ifosfamide and mesna uroprotection). Four cycles of consolidation chemotherapy were given starting 4 weeks after the second concomitant chemobrachyradiotherapy cycle.ResultsAfter median follow-up period of 99.3 months, we observed acceptable acute and late toxicity, local control rate of 97.5%, and an overall survival of 74.6% at 96 months.ConclusionsChemobrachyradiotherapy regimen followed by consolidation chemotherapy described in this article is a valuable treatment option for LACC.
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Severe gastrointestinal complications in the era of image-guided high-dose-rate intracavitary brachytherapy for cervical cancer. Clin Ther 2014; 37:49-60. [PMID: 25444669 DOI: 10.1016/j.clinthera.2014.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/06/2014] [Accepted: 11/06/2014] [Indexed: 11/23/2022]
Abstract
PURPOSE The purposes of this analysis are to report a modern series of severe gastrointestinal toxic effects after definitive chemoradiotherapy in the treatment of locally advanced cervical cancer at our institution and to review the existing literature on factors that contribute to toxic effects and preventive strategies and management. METHODS Our institution's cervical cancer cohort was evaluated for patients with late grade 3 to 4 gastrointestinal toxic effects who were retrospectively reviewed for clinical or dosimetric parameters that could have contributed to late toxic effects. A review of the published literature was performed to identify factors associated with late toxic effects, prophylactic agents, and corrective therapy. FINDINGS Five of 85 patients were identified as having late grade 3 to 4 gastrointestinal toxic effects with a median follow-up of 13.3 months. Two of 5 patients developed late grade 3 toxic effects, and 3 of 5 developed late grade 4 toxic effects. Three of the 5 patients reviewed ultimately required permanent colostomies. Cumulative median dose (in equivalent dose in 2-Gy fractions) of clinical target volume to the hottest 90% was 107.2 Gy, rectal dose to the hottest 2 cc (D2cc) was 81.7 Gy, sigmoid D2cc was 61.7 Gy, and bladder D2cc was 79.5 Gy. No patient had evidence of disease recurrence in the pelvis. One patient developed oligometastatic disease in the suprarenal gland and was successfully salvaged with adrenalectomy. IMPLICATIONS Despite its risk of toxic effects, intracavitary brachytherapy remains a critical component of the treatment of locally advanced cervical cancer. Even with modern radiotherapy planning and delivery techniques, extra attention is warranted to continue to strive for optimal outcomes.
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Christensen EN, Yu HZ, Klopp AH, Tsai JC, Lawyer AA, Court LE, Eifel PJ. Variable impact of intracavitary brachytherapy fractionation schedule on biologically effective dose to organs at risk in patients with cervical cancer. Brachytherapy 2014; 13:240-9. [PMID: 24188993 DOI: 10.1016/j.brachy.2013.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/11/2013] [Accepted: 10/03/2013] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine the effect of intracavitary brachytherapy (ICBT) fractionation schedule on biologically effective dose to organs at risk. METHODS AND MATERIALS We reviewed records from 26 patients who had CT imaging during ICBT for International Federation of Gynecology and Obstetrics stage IB2-IVA cervical cancer. Using α/β=10, we calculated hypothetical nominal doses to achieve a biologically effective dose at 2 Gy per fraction (EQD2α/β=10) of 40 Gy to Point A for high-dose-rate ICBT with 1-15 fractions. Corresponding minimum EQD2α/β=3s to the maximally irradiated 2 cc of rectum, bladder, and sigmoid were calculated for each fractionation scheme and added to EQD2α/β=3 from external beam radiotherapy. Total EQD2α/β=3s were compared with American Brachytherapy Society suggested dose constraints (rectum/sigmoid, ≤75 Gy; bladder, ≤90 Gy). RESULTS Except for rectal EQD2α/β=3 in three patients, the rectal, bladder, and sigmoid EQD2α/β=3s decreased with increasing fractionation in all patients. Although the total rectal EQD2α/β=3s were less than the American Brachytherapy Society rectal dose constraint in all patients at all fractionation schedules, the total bladder EQD2α/β=3s routinely exceeded the bladder dose constraint, even at maximum fractionation. By contrast, increasing fractionation decreased the number of patients with doses exceeding the sigmoid dose constraint by 48%. CONCLUSIONS The relationship between ICBT fractionation schedule and relative EQD2α/β=3s to rectum, bladder, and sigmoid depends on individual anatomy. Fractionation optimization can improve therapeutic ratios by minimizing the risk or severity of toxic effects. For patients in whom many fractions optimize the therapeutic ratio, low-dose-rate or pulsed-dose-rate brachytherapy may be preferred.
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Affiliation(s)
- Eva N Christensen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Henry Z Yu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jillian C Tsai
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann A Lawyer
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Wakatsuki M, Kato S, Ohno T, Karasawa K, Kiyohara H, Tamaki T, Ando K, Tsujii H, Nakano T, Kamada T, Shozu M. Clinical outcomes of carbon ion radiotherapy for locally advanced adenocarcinoma of the uterine cervix in phase 1/2 clinical trial (protocol 9704). Cancer 2014; 120:1663-9. [PMID: 24591084 DOI: 10.1002/cncr.28621] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 01/20/2014] [Accepted: 01/23/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study sought to evaluate the toxicity and efficacy of carbon ion radiotherapy (C-ion RT) for locally advanced adenocarcinoma of the uterine cervix in a phase 1/2 clinical trial. METHODS The treatment consisted of whole-pelvic irradiation of 36.0 gray equivalents (GyE) in 12 fractions and local boost with dose escalation from 26.4 to 38.4 GyE in 8 fractions. The dose escalation was performed with careful observation of acute normal tissue responses. Total dose to the cervical tumor was 62.4 to 74.4 GyE in 20 fractions. RESULTS Between April 1998 and February 2010, 58 patients were treated with C-ion RT in this clinical trial. The number of patients with stage IIB, IIIB, and IVA disease were 20, 35, and 3, respectively. Median tumor size was 5.5 cm (range, 3.0-11.8 cm). Twenty-seven patients had pelvic lymph node metastases. The median follow-up period was 38 months. All patients completed the treatment schedule. Grade 2 or higher late toxicity was found in 8 patients: 5 with bladder and 2 with small intestine grade 2 toxicities, and 1 patient had grade 4 rectal complication, which was surgically salvaged. The 5-year local control rate, local control rate including salvage surgery, and overall survival rate in all cases were 54.5%, 68.2%, and 38.1%, respectively. CONCLUSIONS Dose escalation of C-ion RT for adenocarcinoma of the uterine cervix was accomplished without severe toxicities except in 1 case. Although the number of patients in this study was small, the results support continued investigation and analysis to confirm therapeutic efficacy.
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Affiliation(s)
- Masaru Wakatsuki
- Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, Chiba, Japan
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Better survival with three-dimensional conformal radiotherapy than with conventional radiotherapy for cervical cancer: a population-based study. ISRN ONCOLOGY 2013; 2013:729819. [PMID: 24224099 PMCID: PMC3808715 DOI: 10.1155/2013/729819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 08/27/2013] [Indexed: 12/03/2022]
Abstract
Three-dimensional conformal radiation therapy (3DCRT) has emerged as a preferred treatment for gynecologic malignancies. Yet its superiority to conventional radiotherapy (2-dimensional radiotherapy (2DRT)) for gynecologic malignancies has not been well established. Data from the 2005 to 2010 National Health Insurance Research Database (NHIRD) provided by the National Research Institutes in Taiwan were analyzed to address this issue. Patients were initially diagnosed as having cervical cancer according to the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) code 180, and this clinical diagnosis was confirmed histopathologically or cytologically. Kaplan-Meier method and Cox proportional hazards regression were used to analyze the reported data. Between January 2005 and December 2010, there were 776 patients with newly diagnosed cervical cancer without metastasis, local recurrence, or surgical treatment before RT and 132 and 644 patients, respectively, who received 2DRT and 3DCRT. After adjustment for age, diabetes mellitus, hypertension, coronary heart disease, hyperlipidemia, side effects, urbanization level, geographic region, and enrollee category in the 5-year follow-up period, the HR was 1.82 (95% CI, 1.16–2.85, P = 0.009). The 5-year survival rate in the 2DRT and 3DCRT groups was 73.0% and 82.3%, P = 0.007, respectively. Cervical cancer patients treated with 3DCRT had better overall survival.
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Salani R, O'Malley DM. Here it comes....the role of cost-effective analysis. Gynecol Oncol 2012; 127:265-6. [DOI: 10.1016/j.ygyno.2012.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/24/2012] [Indexed: 10/27/2022]
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Phippen NT, Leath CA, Chino JP, Jewell EL, Havrilesky LJ, Barnett JC. Cost effectiveness of concurrent gemcitabine and cisplatin with radiation followed by adjuvant gemcitabine and cisplatin in patients with stages IIB to IVA carcinoma of the cervix. Gynecol Oncol 2012; 127:267-72. [DOI: 10.1016/j.ygyno.2012.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 08/01/2012] [Accepted: 08/05/2012] [Indexed: 11/26/2022]
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Abstract
ObjectiveTo assess the feasibility and acute toxicity of concurrent chemoradiotherapy (CCRT) with high–dose rate intracavitary brachytherapy (HDR-ICBT) and standard dose delivery of cisplatin for Japanese patients with cervical cancer.Materials and MethodsThe phase 2 study included Japanese patients with International Federation of Gynecology and Obstetrics stage III to IVA uterine cervical cancer who had no para-aortic lymphadenopathy (>10 mm) assessed by computed tomography. Patients were 20 to 70 years of age and had Eastern Cooperative Oncology Group performance status of 0 to 1. The radiotherapy protocol consisted of whole-pelvis external beam radiotherapy and HDR-ICBT. The cumulative linear quadratic equivalent dose (EQD2) was 62 to 65 Gy prescribed at point A. Cisplatin was administered weekly at a dose of 40 mg/m2 for 5 courses.ResultsBetween March 2008 and January 2009, 72 patients from 25 institutions were enrolled, and 71 patients were eligible and evaluable for compliance and severe toxicity. The median age of the patients was 57 years (range, 32–70 years). Sixty-five patients (92%) received the planned 5 courses of chemotherapy. Four patients had cisplatin dose reduction according to the protocol. Radiotherapy was completed per protocol in 68 patients (96%). Median overall treatment time was 50 days (range, 37–66 days). The following grade 3 or 4 acute adverse events were observed: neutropenia in 31 patients (44%), anemia in 10 patients (14%), diarrhea in 4 patients (6%), and anorexia in 3 patients (4%).ConclusionsConcurrent chemoradiotherapy with HDR-ICBT and standard weekly delivery of cisplatin was feasible with acceptable toxicity in Japanese patients with cervical cancer.
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Phase II study of concurrent chemoradiotherapy with high-dose-rate intracavitary brachytherapy in patients with locally advanced uterine cervical cancer: Efficacy and toxicity of a low cumulative radiation dose schedule. Gynecol Oncol 2012; 126:211-6. [DOI: 10.1016/j.ygyno.2012.04.036] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 04/23/2012] [Accepted: 04/24/2012] [Indexed: 11/17/2022]
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Viswanathan AN, Beriwal S, De Los Santos JF, Demanes DJ, Gaffney D, Hansen J, Jones E, Kirisits C, Thomadsen B, Erickson B. American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: high-dose-rate brachytherapy. Brachytherapy 2012; 11:68-75. [PMID: 22265437 DOI: 10.1016/j.brachy.2011.06.008] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/29/2011] [Accepted: 06/30/2011] [Indexed: 12/26/2022]
Abstract
PURPOSE This report presents an update to the American Brachytherapy Society (ABS) high-dose-rate (HDR) brachytherapy guidelines for locally advanced cervical cancer. METHODS Members of the ABS with expertise in cervical cancer formulated updated guidelines for HDR brachytherapy using tandem and ring, ovoids, cylinder, or interstitial applicators for locally advanced cervical cancer. These guidelines were written based on medical evidence in the literature and input of clinical experts in gynecologic brachytherapy. RESULTS The ABS affirms the essential curative role of tandem-based brachytherapy in the management of locally advanced cervical cancer. Proper applicator selection, insertion, and imaging are fundamental aspects of the procedure. Three-dimensional imaging with magnetic resonance or computed tomography or radiographic imaging may be used for treatment planning. Dosimetry must be performed after each insertion before treatment delivery. Applicator placement, dose specification, and dose fractionation must be documented, quality assurance measures must be performed, and followup information must be obtained. A variety of dose/fractionation schedules and methods for integrating brachytherapy with external-beam radiation exist. The recommended tumor dose in 2-Gray (Gy) per fraction radiobiologic equivalence (normalized therapy dose) is 80-90Gy, depending on tumor size at the time of brachytherapy. Dose limits for normal tissues are discussed. CONCLUSION These guidelines update those of 2000 and provide a comprehensive description of HDR cervical cancer brachytherapy in 2011.
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Affiliation(s)
- Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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A Dosimetric Planning Study Comparing Intensity-modulated Radiotherapy with Four-field Conformal Pelvic Radiotherapy for the Definitive Treatment of Cervical Carcinoma. Clin Oncol (R Coll Radiol) 2012; 24:e63-70. [DOI: 10.1016/j.clon.2011.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 04/24/2011] [Accepted: 05/05/2011] [Indexed: 12/11/2022]
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Viswanathan AN, Beriwal S, De Los Santos JF, Demanes DJ, Gaffney D, Hansen J, Jones E, Kirisits C, Thomadsen B, Erickson B. American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: high-dose-rate brachytherapy. Brachytherapy 2012; 11:47-52. [PMID: 22265437 PMCID: PMC3489267 DOI: 10.1016/j.brachy.2011.07.002] [Citation(s) in RCA: 382] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 06/15/2011] [Accepted: 07/08/2011] [Indexed: 01/23/2023]
Abstract
PURPOSE This report presents an update to the American Brachytherapy Society (ABS) high-dose-rate (HDR) brachytherapy guidelines for locally advanced cervical cancer. METHODS Members of the ABS with expertise in cervical cancer formulated updated guidelines for HDR brachytherapy using tandem and ring, ovoids, cylinder, or interstitial applicators for locally advanced cervical cancer. These guidelines were written based on medical evidence in the literature and input of clinical experts in gynecologic brachytherapy. RESULTS The ABS affirms the essential curative role of tandem-based brachytherapy in the management of locally advanced cervical cancer. Proper applicator selection, insertion, and imaging are fundamental aspects of the procedure. Three-dimensional imaging with magnetic resonance or computed tomography or radiographic imaging may be used for treatment planning. Dosimetry must be performed after each insertion before treatment delivery. Applicator placement, dose specification, and dose fractionation must be documented, quality assurance measures must be performed, and followup information must be obtained. A variety of dose/fractionation schedules and methods for integrating brachytherapy with external-beam radiation exist. The recommended tumor dose in 2-Gray (Gy) per fraction radiobiologic equivalence (normalized therapy dose) is 80-90Gy, depending on tumor size at the time of brachytherapy. Dose limits for normal tissues are discussed. CONCLUSION These guidelines update those of 2000 and provide a comprehensive description of HDR cervical cancer brachytherapy in 2011.
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Affiliation(s)
- Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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Gaffney DK, Soisson AP. Simple or complex: optimal therapy for cancer of the cervix. Gynecol Oncol 2010; 119:401-3. [PMID: 21056281 DOI: 10.1016/j.ygyno.2010.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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