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Serarslan A, Daştan Y, Aksu T, Yıldız RE, Gürsel B, Meydan D, Okumuş NÖ. Ninety-degree angled collimator: a dosimetric study related to dynamic intensity-modulated radiotherapy in patients with endometrial carcinoma. BMC Cancer 2023; 23:515. [PMID: 37280543 DOI: 10.1186/s12885-023-11033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/31/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Our purpose was to ensure that the dose constraints of the organs at risk (OARs) were not exceeded while increasing the prescription dose to the planning target volume (PTV) from 45 to 50.4 Gray (Gy) with the dynamic intensity-modulated radiotherapy (IMRT) technique. While trying for this purpose, a new dynamic IMRT technique named 90° angled collimated dynamic IMRT (A-IMRT) planning was developed by us. METHODS This study was based on the computed tomography data sets of 20 patients with postoperatively diagnosed International Federation of Gynecology and Obstetrics stage 2 endometrial carcinoma. For each patient, conventional dynamic IMRT (C-IMRT, collimator angle of 0° at all gantry angles), A-IMRT (collimator angle of 90° at gantry angles of 110°, 180°, 215°, and 285°), and volumetric modulated arc therapy (VMAT) were planned. Planning techniques were compared with parameters used to evaluate PTV and OARs via dose-volume-histogram analysis using the paired two-tailed Wilcoxon's signed-rank test; p < 0.05 was considered indicative of statistical significance. RESULTS All plans achieved adequate dose coverage for PTV. Although the technique with the lowest mean conformality index was A-IMRT (0.76 ± 0.05) compared to both C-IMRT (0.79 ± 0.04, p = 0.000) and VMAT (0.83 ± 0.03, p = 0.000), it protected the OARs especially the bladder (V45 = 32.84 ± 2.03 vs. 44.21 ± 6.67, p = 0.000), rectum (V30 = 56.18 ± 2.05 vs. 73.80 ± 4.75, p = 0.000) and both femoral heads (V30 for right = 12.19 ± 1.34 vs. 21.42 ± 4.03, p = 0.000 and V30 for left = 12.58 ± 1.48 vs. 21.35 ± 4.16, p = 0.000) better than C-IMRT. While the dose constraints of the bladder, rectum and bilateral femoral heads were not exceeded in any patient with A-IMRT or VMAT, they were exceeded in 19 (95%), 20 (100%) and 20 (100%) patients with C-IMRT, respectively. CONCLUSIONS OARs are better protected when external beam radiotherapy is applied to the pelvis at a dose of 50.4 Gy by turning the collimator angle to 90° at some gantry angles with the dynamic IMRT technique in the absence of VMAT.
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Affiliation(s)
- Alparslan Serarslan
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey.
| | - Yalçın Daştan
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey
| | - Telat Aksu
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey
| | - Rana Elif Yıldız
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey
| | - Bilge Gürsel
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey
| | - Deniz Meydan
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey
| | - Nilgün Özbek Okumuş
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, 55139, Turkey
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2
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Wortman BG, Post CCB, Powell ME, Khaw P, Fyles A, D'Amico R, Haie-Meder C, Jürgenliemk-Schulz IM, McCormack M, Do V, Katsaros D, Bessette P, Baron MH, Nout RA, Whitmarsh K, Mileshkin L, Lutgens LCHW, Kitchener HC, Brooks S, Nijman HW, Astreinidou E, Putter H, Creutzberg CL, de Boer SM. Radiation Therapy Techniques and Treatment-Related Toxicity in the PORTEC-3 Trial: Comparison of 3-Dimensional Conformal Radiation Therapy Versus Intensity-Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2021; 112:390-399. [PMID: 34610387 DOI: 10.1016/j.ijrobp.2021.09.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Radiation therapy techniques have developed from 3-dimensional conformal radiation therapy (3DCRT) to intensity modulated radiation therapy (IMRT), with better sparing of the surrounding normal tissues. The current analysis aimed to investigate whether IMRT, compared to 3DCRT, resulted in fewer adverse events (AEs) and patient-reported symptoms in the randomized PORTEC-3 trial for high-risk endometrial cancer. METHODS AND MATERIALS Data on AEs and patient-reported quality of life (QoL) of the PORTEC-3 trial were available for analysis. Physician-reported AEs were graded using Common Terminology Criteria for Adverse Events v3.0. QoL was assessed by the European Organisation for Research and Treatment of Cancer QLQC30, CX24, and OV28 questionnaires. Data were compared between 3DCRT and IMRT. A P value of ≤ .01 was considered statistically significant due to the risk of multiple testing. For QoL, combined scores 1 to 2 ("not at all" and "a little") versus 3 to 4 ("quite a bit" and "very much") were compared between the techniques. RESULTS Of 658 evaluable patients, 559 received 3DCRT and 99 IMRT. Median follow-up was 74.6 months. During treatment no significant differences were observed, with a trend for more grade ≥3 AEs, mostly hematologic and gastrointestinal, after 3DCRT (37.7% vs 26.3%, P = .03). During follow-up, 15.4% (vs 4%) had grade ≥2 diarrhea, and 26.1% (vs 13.1%) had grade ≥2 hematologic AEs after 3DCRT (vs IMRT) (both P < .01). Among 574 (87%) patients evaluable for QoL, 494 received 3DCRT and 80 IMRT. During treatment, 37.5% (vs 28.6%) reported diarrhea after 3DCRT (vs IMRT) (P = .125); 22.1% (versus 10.0%) bowel urgency (P = 0039), and 18.2% and 8.6% abdominal cramps (P = .058). Other QoL scores showed no differences. CONCLUSIONS IMRT resulted in fewer grade ≥3 AEs during treatment and significantly lower rates of grade ≥2 diarrhea and hematologic AEs during follow-up. Trends toward fewer patient-reported bowel urgency and abdominal cramps were observed after IMRT compared to 3DCRT.
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Affiliation(s)
- Bastiaan G Wortman
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Cathalijne C B Post
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Melanie E Powell
- Department of Clinical Oncology, Barts Health NHS Trust, London, United Kingdom
| | - Pearly Khaw
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Romerai D'Amico
- Department of Radiotherapy, Azienda Socio Sanitaria Territoriale, Lecco, Italy
| | | | | | - Mary McCormack
- Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Viet Do
- Radiation Oncology, Liverpool & Macarthur Cancer Therapy Center, NSW, Australia
| | - Dionyssios Katsaros
- Department of Surgical Sciences, Gynecologic Oncology, Città della Salute and Sant'Anna Hospital, University of Turin, Turin, Italy
| | - Paul Bessette
- Gynecologic Oncology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie Hélène Baron
- Department of Radiotherapy, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Henry C Kitchener
- Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Susan Brooks
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Hans W Nijman
- Department of Gynecologic Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Eleftheria Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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3
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Lee TH, Song C, Kim IA, Kim JS, Kim YB, Kim K, No JH, Suh DH, Chung JB, Eom KY. Stereotactic ablative body radiotherapy boost for cervical cancer when brachytherapy boost is not feasible. Radiat Oncol 2021; 16:148. [PMID: 34384450 PMCID: PMC8359558 DOI: 10.1186/s13014-021-01877-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to analyze the treatment efficacy and safety of stereotactic ablative body radiotherapy (SABR) boost for cervical cancer patients not amenable to brachytherapy. METHODS A retrospective review of the medical records from single institution of 25 eligible patients was performed. The patients underwent pelvic radiotherapy (RT) in 25 or 28 fractions with a median dose of 45 Gy (range 44-50.4 Gy). SABR boost was delivered after pelvic RT, with a median dose of 25 Gy (range 20-33 Gy), and a median fraction number of 5 (range 4-6). 21 patients with a follow-up period of more than one year were included in the toxicity analysis, and hematuria and hematochezia that occurred later than 3 months after the RT were graded. RESULTS The median follow-up period after radiotherapy was 2.85 years (range 0.33-6.60). The 3-year local control, locoregional control, disease-free survival, and overall survival rates were 80.9%, 75.8%, 40.9%, and 77.1%, respectively. 5 patients experienced grade 3 toxicity (3 genitourinary, 3 gastrointestinal), and no grade 4-5 toxicity was reported. Univariate analysis showed that cumulative D2cc in equivalent dose in 2 Gy fractions (EQD2) of rectum was marginally predictive for any grade of hematochezia (P = 0.051). Cumulative D2cc EQD2 of bladder was not predictive for hematuria. In the receiver operating characteristic (ROC) curve analysis, the optimal threshold of cumulative rectal D2cc EQD2 was 81.2 Gy for any grade of hematochezia. CONCLUSION SABR boost for cervical cancer was effective and tolerable. Although it cannot substitute brachytherapy, it can be a treatment option when brachytherapy is not possible.
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Affiliation(s)
- Tae Hoon Lee
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Hong No
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin-Beom Chung
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Keun-Yong Eom
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.
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Impact of adjuvant radiotherapy on the survival of women with optimally resected stage III endometrial cancer in the era of modern radiotherapy: a retrospective study. Radiat Oncol 2020; 15:72. [PMID: 32252781 PMCID: PMC7137232 DOI: 10.1186/s13014-020-01523-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
Background The optimal adjuvant treatment for stage III endometrial cancer in the era of modern radiotherapy remains undefined. We investigated the benefit of adjuvant radiotherapy for women who underwent optimal resection for stage III endometrial cancer in the era of modern radiotherapy. Methods We retrospectively reviewed patients with endometrial cancer who were treated between 2010 and 2018. Adjuvant treatment included radiotherapy by modern radiotherapy techniques (intensity-modulated or volumetric modulated arc radiotherapy), chemotherapy, or both. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method and analyzed via multivariate Cox proportional hazards models. Results One hundred sixty-one patients were initially included (52, 9, and 100 with stages IIIA, IIIB, and IIIC cancer, respectively); 154 patients (96%) received adjuvant therapy. Such adjuvant treatment was associated with improved RFS (p = 0.014) and OS (p = 0.044) over surgery alone. Adjuvant radiotherapy by modern radiotherapy techniques led to low incidence of acute (25%) and chronic (7%) grade ≥ 2 gastrointestinal toxicity. On univariate analysis, non-endometrioid histology and grade 3 status were associated with higher risks of tumor recurrence and death, whereas adjuvant radiotherapy alone or in combination chemotherapy reduced their risks. On multivariate analysis, non-endometrioid histology was associated with increased recurrence (hazard ratio [HR], 2.95; p = 0.009), whereas adjuvant radiotherapy alone or with chemotherapy was associated with lower recurrence (HR, 0.62; p = 0.042). Patients > 60 years of age (p = 0.038) as well as those with endometrioid histology (p = 0.045), lymphovascular space invasion (p = 0.031), and ≥ 2 positive lymph nodes (p = 0.044) benefited most from adjuvant radiotherapy. Conclusions Modern adjuvant radiotherapy (intensity-modulated or volumetric modulated arc radiotherapy) alone or with chemotherapy should be considered for women with optimally resected stage III endometrial cancer. Trial registration ClinicalTrials.gov, NCT04251676. Registered 24 January 2020. Retrospectively registered.
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Huang MY, Huang CW, Wang JY. Surgical treatment following neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Kaohsiung J Med Sci 2019; 36:152-159. [PMID: 31814296 DOI: 10.1002/kjm2.12161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/11/2019] [Indexed: 01/02/2023] Open
Abstract
Colorectal cancer is a major public health problem worldwide, and locally advanced rectal cancer (LARC) is known for its poor prognosis. A multimodal treatment approach is the only method to achieve satisfactory local recurrence and survival rates in LARC. Determining which therapeutic modality for LARC has the most satisfactory influence on quality of life and disease outcome is still controversial. LARC treatment is subject to continuous advancement due to the development of new and better diagnostic tools, radiotherapy techniques, and chemotherapeutic agents. Herein, we review various therapeutic modalities for LARC from several aspects. In addition to radiotherapy techniques such as neoadjuvant chemoradiotherapy (NCRT), we discuss the progress of chemotherapy, appropriate time interval between NCRT and surgery, relationship between tumor location and NCRT efficacy/safety, wait-and-watch policy, and predictors of treatment response following NCRT. Because of the controversies and unanswered questions regarding NCRT treatments for LARC, additional investigations are required to determine which therapeutic approach is the most feasible for LARC patients.
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Affiliation(s)
- Ming-Yii Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.,Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.,Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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6
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Abstract
Radiotherapy plays a critical role in the management of cervix carcinoma, in the adjuvant setting for patients with high-risk pathologic features and in the definitive setting for locoregionally advanced disease. External beam radiotherapy fields encompass potential areas of microscopic disease spread in addition to known areas of gross disease. In the presence of gross disease, however, escalation of dose is required that is best accomplished using a brachytherapy boost to spare surrounding normal organs from toxicity. This article addresses indications for radiotherapy in the management of nonmetastatic cervix cancer and reviews various radiotherapy techniques, with a heavy focus on brachytherapy.
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Affiliation(s)
- Lana de Souza Lawrence
- Department of Radiation Oncology, Christiana Care Health Services, 4701 Ogletown Stanton Road, Suite 1109, Newark, DE 19713, USA.
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7
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Kwak YK, Lee SW, Kay CS, Park HH. Intensity-modulated radiotherapy reduces gastrointestinal toxicity in pelvic radiation therapy with moderate dose. PLoS One 2017; 12:e0183339. [PMID: 28846718 PMCID: PMC5573121 DOI: 10.1371/journal.pone.0183339] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/02/2017] [Indexed: 12/25/2022] Open
Abstract
This retrospective study was performed to evaluate and compare gastrointestinal (GI) toxicities caused by conventional radiotherapy (cRT) and intensity modulated radiotherapy (IMRT) in 136 cancer patients treated with pelvic radiotherapy (RT) with moderate radiation dose in a single institution. A matched-pair analysis of the two groups was performed; each group included 68 patients. Conventional RT was delivered using the four-field box technique and IMRT was delivered with helical tomotherapy. The median daily dose was 1.8 Gy and the median total dose was 50.4 Gy (range 25.2–56 Gy). Primary end point was GI toxicity during and after RT. Secondary end point was factors that affect toxicity. Patients treated with IMRT had lower incidence of grade ≥ 2 acute GI toxicity compared to the patients treated with cRT (p = 0.003). The difference remained significant in multivariate analysis (p = 0.01). The incidence of chronic GI toxicity was not statistically different between the two groups, but the cRT group had higher incidence of grade 3 chronic GI toxicity. Based on our results, IMRT can reduce GI toxicity compared to cRT in the treatment of pelvic radiotherapy even with moderate radiation dose and this will enhance patients’ quality of life and treatment compliance.
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Affiliation(s)
- Yoo-Kang Kwak
- Department of Radiation Oncology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sea-Won Lee
- Department of Radiation Oncology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Seung Kay
- Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
| | - Hee Hyun Park
- Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
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Mahmoud O, Kilic S, Khan AJ, Beriwal S, Small W. External beam techniques to boost cervical cancer when brachytherapy is not an option-theories and applications. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:207. [PMID: 28603722 DOI: 10.21037/atm.2017.03.102] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The management of locally advanced cervical cancer relies on brachytherapy (BT) as an integral part of the radiotherapy delivery armamentarium. Occasionally, intracavitary BT is neither possible nor available. In these circumstances, post-external beam radiotherapy (EBRT) interstitial brachytherapy and/or hysterectomy may represent viable options that must be adequately executed in a timely manner. However, if these options are not applicable due to patient related or facility related reasons, a formal contingency plan should be in place. Innovative EBRT techniques such as intensity modulated and stereotactic radiotherapy may be considered for patients unable to undergo brachytherapy. Relying on provocative arguments and recent data, this review explores the rationale for and limitations of non-brachytherapy substitutes in that setting aiming to establish a formal process for the optimal execution of this alternative plan.
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Affiliation(s)
- Omar Mahmoud
- Department of Radiation Oncology, Rutgers, the State University of New Jersey, Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Department of Radiation Oncology, Rutgers, the State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Sarah Kilic
- Department of Radiation Oncology, Rutgers, the State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers, the State University of New Jersey, Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Department of Radiation Oncology, Rutgers, the State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Sushil Beriwal
- Departement of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - William Small
- Department of Radiation Oncology, Loyola University, Chicago, IL, USA
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9
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Huang CM, Huang MY, Tsai HL, Huang CW, Ma CJ, Lin CH, Huang CJ, Wang JY. A retrospective comparison of outcome and toxicity of preoperative image-guided intensity-modulated radiotherapy versus conventional pelvic radiotherapy for locally advanced rectal carcinoma. JOURNAL OF RADIATION RESEARCH 2017; 58:247-259. [PMID: 27738080 PMCID: PMC5571614 DOI: 10.1093/jrr/rrw098] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/18/2016] [Indexed: 05/12/2023]
Abstract
The aim of the study was to compare clinical outcomes and toxicity between 3D conformal radiotherapy (3DCRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) administered through helical tomotherapy in locally advanced rectal cancer (LARC) patients receiving preoperative chemoradiotherapy. We reviewed 144 patients with Stage II-III rectal cancer receiving preoperative fluoropyrimidine-based chemoradiotherapy followed by radical resection. Tumor responses following chemoradiotherapy were evaluated using the Dworak tumor regression grade (TRG). Of the 144 patients, 45 received IG-IMRT and 99 received 3DCRT. A significant reduction in Grade 3 or 4 acute gastrointestinal toxicity (IG-IMRT, 6.7%; 3DCRT, 15.1%; P = 0.039) was observed by IG-IMRT. The pathologic complete response (pCR) rate did not differ between the IG-IMRT and the 3DCRT group (17.8% vs 15.1%, P = 0.52). Patients in the IG-IMRT group had the trend of favorable tumor regressions (TRG 3 or 4) compared with those in the 3DCRT group (66.7% vs 43.5%, P = 0.071). The median follow-up was 53 months (range, 18-95 months) in the 3DCRT group and 43 months (range, 17-69 months) in the IG-IMRT group. Four-year overall, disease-free, and local failure-free survival rates of the IG-IMRT and 3DCRT groups were 81.6% and 67.9% (P = 0.12), 53.8% and 51.8% (P = 0.51), and 88% and 75.1% (P = 0.031), respectively. LARC patients treated with preoperative IG-IMRT achieved lower acute gastrointestinal adverse effects and a higher local control rate than those treated with 3DCRT, but there was no prominent difference in distant metastasis rate and overall survival between two treatment modalities.
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Affiliation(s)
- Chun-Ming Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Ming-Yii Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Hsiang-Lin Tsai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of General Surgery Medicine, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Ching-Wen Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Cheng-Jen Ma
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Chih-Hung Lin
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Chih-Jen Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Jaw-Yuan Wang
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Center for Environmental Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Corresponding author. Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan. Tel: +88-6-7-312-2805; Fax: +88-6-7-311-4679; ;
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Vergalasova I, Light K, Chino J, Craciunescu O. Simultaneous integrated boost (SIB) for treatment of gynecologic carcinoma: Intensity-modulated radiation therapy (IMRT) vs volumetric-modulated arc therapy (VMAT) radiotherapy. Med Dosim 2017; 42:230-237. [DOI: 10.1016/j.meddos.2017.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 04/26/2017] [Accepted: 05/18/2017] [Indexed: 01/13/2023]
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Sung W, Kim JI, Kim HS, Kim HJ, Lee YH, Ye SJ. Performance of the irregular surface compensator compared with four-field box and intensity modulated radiation therapy for gynecologic cancer. Phys Med 2016; 32:1537-1542. [PMID: 27866896 DOI: 10.1016/j.ejmp.2016.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 10/28/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE A retrospective planning study was undertaken to evaluate the dosimetric advantages of the irregular surface compensator (ISC) technique, a forward planning technique with electronic compensation algorithm available on Varian Eclipse treatment planning system. This was extensively compared to the conventional four-field box (4FB) and intensity modulated radiation therapy using 5 fields (IMRT5F) on gynecologic cancer patients. METHODS Twenty-two patients were enrolled. The prescribed dose was 50.4Gy in 28 fractions to the primary target including pelvic lymph nodes. 4FB treatment plans were generated, then fluence of anterior and posterior fields were modified to generate ISC plans. IMRT5F were inversely optimized with equally spaced five coplanar fields. Dose-volume parameters were evaluated for the comparison of three planning techniques. The MU and delivery time were also estimated. RESULTS In terms of target coverage, the conformity and homogeneity index of ISC (1.67 and 1.03, respectively) were superior to those of 4FB (2.43 and 1.06, respectively) but slightly inferior to those of IMRT5F (1.10 and 1.02, respectively). ISC also illustrated an overall improvement in normal organ saving. Compared to 4FB, the mean dose of the rectum was reduced by about 4.0-5.0Gy with ISC and IMRT5F. The volume receiving large doses was reduced for bladder with statistical significance with ISC and more with IMRT5F relative to 4FB. The mean number of MU per fraction were 200.86 (4FB), 446.09 (ISC) and 895.59 (IMRT5F). CONCLUSION The ISC technique has the superior target coverage and healthy tissue sparing in comparison with conventional 4FB and comparable normal organ saving compared to IMRT5F. The ISC can be an available option for gynecologic radiotherapy.
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Affiliation(s)
- Wonmo Sung
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Seoul National University Graduate School of Convergence Science and Technology, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-In Kim
- Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea; Center for Convergence Research on Robotics, Advanced Institutes of Convergence Technology, Suwon, Republic of Korea.
| | - Hyun Suk Kim
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Seoul National University Graduate School of Convergence Science and Technology, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Yang Hoon Lee
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung-Joon Ye
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Seoul National University Graduate School of Convergence Science and Technology, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
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Cihoric N, Tsikkinis A, Tapia C, Aebersold DM, Zlobec I, Lössl K. Dose escalated intensity modulated radiotherapy in the treatment of cervical cancer. Radiat Oncol 2015; 10:240. [PMID: 26597282 PMCID: PMC4657246 DOI: 10.1186/s13014-015-0551-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 11/18/2015] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Standard dose of external beam radiotherapy seems to be insufficient for satisfactory control of loco-regionally advanced cervical cancer. Aim of our study is to evaluate the outcome as well as early and chronic toxicities in patients with loco-regionally advanced cervical cancer, treated with dose escalated intensity modulated radiotherapy (IMRT) combined with cisplatin chemotherapy. MATERIAL AND METHODS Thirty-nine patients with cervical carcinoma FIGO stage IB2 - IVA were treated with curative intent between 2006 and 2010. The dose of 50.4 Gy was prescribed to the elective pelvic nodal volume. Primary tumors < 4 cm in diameter (n = 6; 15.4 %) received an external beam radiotherapy (EBRT) boost of 5.4 Gy, primary tumors > 4 cm in diameter (n = 33; 84.6 %) received an EBRT boost of 9 Gy. Patients with positive lymph nodes detected with (18)FDG-PET/CT (n = 22; 56.4 %) received a boost to a total dose of 59.4 - 64.8 Gy. The para-aortic region was included in the radiation volume in 8 (20.5 %) patients and in 5 (12.8 %) patients the para-aortic macroscopic lymph nodes received an EBRT boost. IMRT was followed with a 3D planned high dose rate intrauterine brachytherapy given to 36 (92.3 %) patients with a total dose ranging between 15-18 Gy in three fractions (single fraction: 4-6.5 Gy). Patients without contraindications (n = 31/79.5 %) received concomitantly a cisplatin-based chemotherapy (40 mg/kg) weekly. Toxicities were graded according to the common terminology criteria for adverse events (CTCAE v 4.0). RESULTS Mean overall survival for the entire cohort was 61.1 months (±3.5 months). Mean disease free survival was 47.2 months (±4.9 months) and loco-regional disease free survival was 55.2 months (±4.4 months). 65 % of patients developed radiotherapy associated acute toxicities grade 1, ca. 30 % developed toxicities grade 2 and just two (5.2 %) patients developed grade 3 toxicities, one acute diarrhea and one acute cystitis. 16 % of patients had chronic toxicities grade 1, 9 % grade 2 and one patient (2.6 %) toxicities grade 3 in the form of vaginal dryness. CONCLUSION Dose escalated IMRT appears to have a satisfactory outcome with regards to mean overall survival, disease free and loco-regional disease free survival, whereas the treatment-related toxicities remain reasonably low.
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Affiliation(s)
- Nikola Cihoric
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
| | - Alexandros Tsikkinis
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
| | - Coya Tapia
- University of Bern, Institute for Pathology, Murtenstrasse 31, Bern, 3010, Switzerland. .,Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center Life Science Plaza, 2130 W. Holcombe, Blvd. Unit 2951, Houston, 77030, TX, USA.
| | - Daniel M Aebersold
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
| | - Inti Zlobec
- University of Bern, Institute for Pathology, Murtenstrasse 31, Bern, 3010, Switzerland.
| | - Kristina Lössl
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
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Merrow C, deBoer S, Podgorsak MB. VMAT for the treatment of gynecologic malignancies for patients unable to receive HDR brachytherapy. J Appl Clin Med Phys 2014; 15:4839. [PMID: 25207568 PMCID: PMC5711077 DOI: 10.1120/jacmp.v15i5.4839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 06/03/2014] [Accepted: 05/23/2014] [Indexed: 12/01/2022] Open
Abstract
This investigation studies the use of volumetric-modulated arc therapy (VMAT) to deliver the following conceptual gynecological brachytherapy (BT) dose distributions: Type 1, traditional pear-shaped dose distribution with substantial dose gradients; Type 2, homogeneous dose distribution throughout PTV (BT prescription volume); and Type 3, increased dose to PTV without organ-at-risk (OAR) overdose. A tandem and ovoid BT treatment plan, with the prescription dose of 6 Gy to point A, was exported into the VMAT treatment planning system (TPS) and became the baseline for comparative analysis. The 200%, 150%, 130%, 100%, 75%, and 50% dose volumes were converted into structures for optimization and evaluation purposes. The 100% dose volume was chosen to be the PTV. Five VMAT plans (Type 1) were created to duplicate the Ir-192 tandem and ovoid inhomogeneous dose distribution. Another five VMAT plans (Type 2) were generated to deliver a homogeneous dose of 6 Gy to the PTV. An additional five VMAT plans (Type 3) were created to increase the dose to the PTV with a homogeneous dose distribution. In the first set of plans, the dose given to 99% of the 200%-100% dose volumes agreed within 2% of the BT plan on average. Additionally, it was found that the 75% dose volumes agreed within 5% of the BT plan and the 50% dose volumes agreed within 6.4% of the BT plan. In the second set of comparative analyses, the 100% dose volume was found to be within 1% of the original plan. Furthermore, the maximum increase of dose to the PTV in the last set of comparative analyses was 8 Gy with similar doses to OARs as the other VMAT plans. The maximum increase of dose was 2.50 Gy to the rectum and the maximum decrease of dose was 0.70 Gy to the bladder. Henceforth, VMAT was successful at reproducing brachytherapy dose distributions demonstrating that alternative dose distributions have the potential to be used in lieu of brachytherapy. It should also be noted that differences in radiobiology need to be further investigated.
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Does obesity hinder radiotherapy in endometrial cancer patients? The implementation of new techniques in adjuvant radiotherapy - focus on obese patients. MENOPAUSE REVIEW 2014; 13:96-100. [PMID: 26327837 PMCID: PMC4520346 DOI: 10.5114/pm.2014.42710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 02/07/2014] [Accepted: 02/17/2014] [Indexed: 11/17/2022]
Abstract
The increasing incidence of obesity in Poland and its relation to endometrioid endometrial cancer (EEC) is resulting in the increasing necessity of treating obese women. Treatment of an overweight patient with EEC may impede not only the surgical procedures but also radiotherapy, especially external beam radiotherapy (EBRT). The problems arise both during treatment planning and when delivering each fraction due to the difficulty of positioning such a patient – it implies the danger of underdosing targets and overdosing organs at risk. Willingness to use dynamic techniques in radiation oncology has increased for patients with EEC, even those who are obese. During EBRT careful daily verification is necessary for both safety and treatment accuracy. The most accurate method of verification is cone beam computed tomography (CBCT) with soft tissue assessment, although it is time consuming and often requires a radiation oncologist. In order to improve the quality of such treatment, the authors present the practical aspects of planning and treatment itself by means of dynamic techniques in EBRT. The authors indicate the advantages and disadvantages of different types of on-board imaging (OBI) verification images. Considering the scanty amount of literature in this field, it is necessary to conduct further research in order to highlight proper planning and treatment of obese endometrial cancer patients. The review of the literature shows that all centres that wish to use EBRT for gynaecological tumours should develop their own protocols on qualification, planning the treatment and methods of verifying the patients’ positioning.
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IMRT with ¹⁸FDG-PET\CT based simultaneous integrated boost for treatment of nodal positive cervical cancer. Radiat Oncol 2014; 9:83. [PMID: 24661323 PMCID: PMC4014138 DOI: 10.1186/1748-717x-9-83] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/16/2014] [Indexed: 12/11/2022] Open
Abstract
Background To evaluate toxicity and outcome of intensity modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to the positive lymph nodes in patients with loco-regional advanced cervical cancer (LRACC). Methods The study population comprised ten patients with 18FDG-PET\CT positive lymph nodes (LNs), who underwent chemoradiation with IMRT and SIB. A dose of 50.4 Gy, in daily fractions of 1.8 Gy, was delivered to primary tumor and draining LNs. Primary tumor received an additional external beam boost to a total dose of 55.8 Gy. A SIB of 62 Gy, in daily fractions of 2 Gy, was delivered to the 18FDG-PET\CT positive LNs. Finally, a high dose rate brachytherapy (HDRB) boost (15 – 18 Gy) was administered to the primary tumor. The primary goal of this study was to evaluate acute and early late toxicity and loco-regional control. Results The median number of irradiated LNs per patient was 3 (range: 1–6) with a median middle nodal SIB-volume of 26.10 cm3 (range, 11.9-82.50 cm3). Median follow-up was 20 months (range, 12 to 30 months). Acute and late grade 3 toxicity was observed in 1 patient. Three of the patients developed a recurrence, one in the form of a local tumor relapse, one had a paraaortic LN metastasis outside the treated volume and the last one developed a distant metastasis. Conclusion IMRT with SIB in the region of 18FDG-PET positive lymph nodes appears to be an effective therapy with acceptable toxicity and might be useful in the treatment of patients with locally advanced cervical cancer.
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Fernandez-Ots A, Crook J. The role of intensity modulated radiotherapy in gynecological radiotherapy: Present and future. Rep Pract Oncol Radiother 2013; 18:363-70. [PMID: 24416580 DOI: 10.1016/j.rpor.2013.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/13/2013] [Accepted: 08/02/2013] [Indexed: 10/26/2022] Open
Abstract
AIM This manuscript reviews the English language literature on the use of intensity modulated radiation therapy (IMRT) for gynecologic malignancies, focusing on the treatment cervical cancer. BACKGROUND Radiation therapy plays a key role in both definitive and adjuvant treatment of these patients, although efforts continue to minimize acute and chronic toxicity. IMRT is an attractive option because of the potential to dose escalate to the target while sparing organs at risk. METHODS AND MATERIALS The English language literature was reviewed for relevant studies. RESULTS Multiple heterogeneous studies have showed dosimetric and clinical benefits with reduction in acute and late gastrointestinal, genitourinary and hematologic toxicity, especially in the post hysterectomy scenario and for dose escalation to para-aortic nodes. Consensus is evolving regarding necessary margins and target delineation in the context of organ movement and tumor shrinkage during the course of radiotherapy. Protocols with daily soft-tissue visualization are being investigated. CONCLUSIONS Consistency in approach and reporting are vital in order to acquire the data to justify the considerable increased expense of IMRT.
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Affiliation(s)
- Ana Fernandez-Ots
- British Columbia Cancer Agency, Center for the Southern Interior, 399 Royal Avenue, Kelowna, British Columbia, Canada V1Y 5L3
| | - Juanita Crook
- British Columbia Cancer Agency, Center for the Southern Interior, 399 Royal Avenue, Kelowna, British Columbia, Canada V1Y 5L3
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Latifi K, Zhang GG, Moros EG, Harris EE. Assessment of intact cervix motion using implanted fiducials in patients treated with helical tomotherapy with daily MVCT positioning. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13566-013-0113-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Monroe AT, Pikaart D, Peddada AV. Clinical outcomes of image guided radiation therapy (IGRT) with gold fiducial vaginal cuff markers for high-risk endometrial cancer. Acta Oncol 2013; 52:1010-6. [PMID: 22998475 DOI: 10.3109/0284186x.2012.721932] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To report two year clinical outcomes of image guided radiation therapy (IGRT) to the vaginal cuff and pelvic lymph nodes in a series of high-risk endometrial cancer patients. METHODS Twenty-six consecutive high-risk endometrial cancer patients requiring adjuvant radiation to the vaginal cuff and regional lymph nodes were treated with vaginal cuff fiducial-based IGRT. Seventeen (65%) received sequential chemotherapy, most commonly with a sandwich technique. Brachytherapy followed external radiation in 11 patients to a median dose of 18 Gy in 3 fractions. The median external beam dose delivered was 47.5 Gy in 25 fractions. RESULTS All 656 fractions were successfully imaged and treated. The median overall translational shift required for correction was 9.1 mm (standard deviation, 5.2 mm) relative to clinical set-up with skin tattoos. Shifts of 1 cm, 1.5 cm, and 2 cm or greater were performed in 43%, 14%, and 4% of patients, respectively. Acute grade 2 gastrointestinal (GI) toxicity occurred in eight patients (30%) and grade 3 toxicity occurred in one. At two years, there have been no local or regional failures and actuarial overall survival is 95%. CONCLUSION Daily image guidance for high-risk endometrial cancer results in a low incidence of acute GI/genitourinary (GU) toxicity with uncompromised tumor control at two years. Vaginal cuff translations can be substantial and may possibly result in underdosing if not properly considered.
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Affiliation(s)
- Alan T Monroe
- Department of Radiation Oncology, Penrose Cancer Center, Colorado Springs, CO 80907, USA.
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Kadkhodayan S, Homaei Shandiz F, Seilanian Toussi M, Afzal Aghaee M, Farshidi F, Dehghan P. Concurrent Chemoradiotherapy without Brachytherapy in Locally Advanced Cervical Cancer. IRANIAN JOURNAL OF CANCER PREVENTION 2013; 6:195-200. [PMID: 25250134 PMCID: PMC4142937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Accepted: 09/03/2003] [Indexed: 11/21/2022]
Abstract
BACKGROUND Concurrent chemoradiotherapy (EBRT + cisplatin) plus intracavitary brachytherapy is the standard of care in patients with advanced cervical cancer. However, a number of patients could not undergone brachytherapy due to massive residual tumor or anatomical distortion. In this study, we have evaluated the treatment outcome in patients with locally advanced cervical cancer, undergone conventional EBRT plus cisplatin based chemotherapy. METHODS IN THIS STUDY, WE HAVE SELECTED PATIENTS WITH LOCALLY ADVANCED CERVICAL CARCINOMA (STAGE: IIB to IIIB) undergone external beam radiotherapy and chemotherapy without brachytherapy at our institute between October of 2007 and October of 2009. The patients have received 50 Gy within 5 weeks to whole pelvic that has followed by a localized boost dose on tumor to 70 Gy concurrently with cisplatin 35 mg/m2 weekly. The treatment has related toxicities, and survival (overall and disease free) have evaluated. RESULTS 30 cases with a median age of 55 (range; 40 to 73) have been studied. According to FIGO classification, the clinical stages were as follows: stage: IIB 23, IIIA 4, and IIIB 3 cases. Three months after treatment, 19 patients (63.3%) have achieved complete response. With a median follow up time of 18 months (range; 10-33 months), 8/23 cases (34.7%) with stage IIB and 2/7 (28.5%) among stage IIIA-IIIB remained disease free at the end of follow up. Data have shown a 2-year overall survival rate of 58.7% ± 9% and 2- year disease free survival of 37.7% ± 9% . Most toxicities were grade I and II. 2 (6.6%) grade III diarrhea and 4 (13.3%) grade III neutropenia have recorded. CONCLUSION Although a considerable number of patients have achieved complete response using concurrent chemoradiotherapy without brachytherapy, the overall treatment outcomes especially for stage IIIA-IIIB were unsatisfactory. Using modern radiation therapy techniques with increased delivered boost dose could improve treatment results.
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Affiliation(s)
- Sima Kadkhodayan
- Women’s Health Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Homaei Shandiz
- Solid Tumor Treatment Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran,Corresponding Author:
Fatemeh Homaei Shandiz, MD;
Associate professor of Radiation
Oncology
Tel: (+98) 511 801 24 77
| | - Mehdi Seilanian Toussi
- Solid Tumor Treatment Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Farnoosh Farshidi
- Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Parvane Dehghan
- Dept. of Radiation Oncology, Mashhad University of Medical Sciences, Mashhad, Iran
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Yavas G, Yavas C, Acar H, Buyukyoruk A, Cobanoglu G, Kerimoglu OS, Yavas O, Celik C. Dosimetric comparison of 3-dimensional conformal and field-in-field radiotherapy techniques for the adjuvant treatment of early stage endometrial cancer. Phys Med 2012; 29:577-82. [PMID: 23219336 DOI: 10.1016/j.ejmp.2012.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/30/2012] [Accepted: 11/12/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The purpose of this study is to compare field-in-field radiotherapy (FIF) with conformal radiotherapy (CRT) in terms of dosimetric benefits for early stage endometrial cancer patients. MATERIALS AND METHODS Ten consecutive early stage endometrial cancer patients who underwent adjuvant external beam radiotherapy were included in the study. For each patient, two different treatment plans were created. FIF and CRT plans were compared for doses in the planning target volume (PTV), the organ at risk (OAR) volumes including rectum, bladder, bowel, bilateral femurs and bone marrow, the dose homogeneity index, and the monitor unit counts required for the treatment. RESULTS The FIF technique significantly reduced the maximum dose of the PTV, rectum, bladder, bowel, left femur, right femur and bone marrow (p values were: <0.001, 0.031, 0.003, <0.001, 0.001, 0.001 and <0.001 respectively). When the OAR volumes irradiated with >30 and >45 Gy were compared, the results were in favor of the FIF technique. The volumes of rectum, bladder, bowel, left femur, right femur and bone marrow receiving more than the prescription dose of 45 Gy were significantly reduced with FIF technique (p values were 0.016, 0.039, 0.01, 0.04, 0.037 and 0.01 respectively). The dose homogeneity index (DHI) was significantly improved with FIF technique (p < 0.001). CONCLUSIONS FIF allowed more homogeneous dose distribution in the PTV and reduced the doses received by OAR. Considering the lower maximum doses in the OAR and PTV, FIF technique seems to be more advantageous than CRT during adjuvant radiotherapy for early stage endometrial cancer patients.
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Affiliation(s)
- Guler Yavas
- Selcuk University, Faculty of Medicine, Department of Radiation Oncology, 42075 Konya, Turkey.
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Du XL, Tao J, Sheng XG, Lu CH, Yu H, Wang C, Song QQ, Li QS, Pan CX. Intensity-modulated radiation therapy for advanced cervical cancer: a comparison of dosimetric and clinical outcomes with conventional radiotherapy. Gynecol Oncol 2011; 125:151-7. [PMID: 22198339 DOI: 10.1016/j.ygyno.2011.12.432] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 12/05/2011] [Accepted: 12/12/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the dosimetry, efficacy and toxicity of reduced field intensity-modulated radiation therapy (RF-IMRT) for patients with advanced cervical cancer. METHODS From August 2005 to August 2010, 60 patients with stage IIB-IIIB cervical cancer underwent reduced field IMRT (RF-IMRT group) and 62 patients treated with conventional radiotherapy (c-RT group) were enrolled. The RF-IMRT plans were as follows: whole pelvic IMRT plan was performed to deliver a dose of 30Gy firstly, then the irradiated volume was reduced to lymphatic drainage region as well as paracervix and parametrium for an additional 30Gy boost. Intracavitary brachytherapy and concurrent chemotherapy were performed during external irradiation. The tumor coverage and normal tissue avoidance were evaluated. Treatment response, toxicities and survival were assessed. RESULTS The mean dose delivered to the planning target volume was significantly higher in RF-IMRT group than in c-RT group (61.5 vs. 50.8Gy, P=0.046). IMRT plans yielded better dose conformity to the target and better sparing of the rectal, bladder and small intestine. The RF-IMRT patients experienced significantly lower acute and chronic toxicities with comparable short-term effects than did those treated with conventional RT (CR: 87.7% vs. 88.3%, P=0.496; PR: 7.0% vs. 6.7%, P=0.440). No significant differences were found between treatment groups for 1year, 3year, and 5year overall survival (OS) levels, although the latter approached statistical significance in favor of IMRT, while a significantly higher progression-free survival (PFS; P=0.031) was seen for IMRT. CONCLUSIONS RF-IMRT yields improved dose distributions, with lower toxicities, while providing comparable clinical outcomes. The increased PFS may be an advantage.
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Affiliation(s)
- Xue-lian Du
- Department of Gynecologic Oncology, Shandong Cancer Hospital, Jinan, People's Republic of China
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Assessment of Organ Motion in Postoperative Endometrial and Cervical Cancer Patients Treated With Intensity-Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2011; 81:e645-50. [DOI: 10.1016/j.ijrobp.2011.01.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 01/07/2011] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
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Mazeron R, Gilmore J, Khodari W, Dumas I, Haie-Méder C. [Locally advanced cervical cancer: Should intensity-modulated radiotherapy replace brachytherapy?]. Cancer Radiother 2011; 15:477-83. [PMID: 21880534 DOI: 10.1016/j.canrad.2011.07.232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 07/19/2011] [Indexed: 12/31/2022]
Abstract
Intensity-modulated conformal radiotherapy (IMRT) is booming as treatment of locally advanced cervical cancer. This technique reduces the doses delivered to organs at risk and, by analogy to the irradiation of prostate cancer, opens the door to the possibility of dose escalation to levels close or similar to those achieved by brachytherapy. To date, several studies comparing IMRT with brachytherapy have been published, often methodologically flawed, concluding sometimes that both techniques are comparable. These results should be taken with extreme caution and should not overshadow the recent advances in brachytherapy with the use of 3D imaging and optimization. Preliminary works also showed that the combination of 3D optimized brachytherapy with IMRT could improve the management of the local disease especially for lesions poorly covered by intracavitary techniques.
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Affiliation(s)
- R Mazeron
- Service de radiothérapie, institut de cancérologie Gustave-Roussy, Villejuif cedex, France.
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Chen CC, Lin JC, Jan JS, Ho SC, Wang L. Definitive intensity-modulated radiation therapy with concurrent chemotherapy for patients with locally advanced cervical cancer. Gynecol Oncol 2011; 122:9-13. [DOI: 10.1016/j.ygyno.2011.03.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/18/2011] [Accepted: 03/26/2011] [Indexed: 10/18/2022]
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Rodríguez Villalba S, Planell CDC, Grau JMC. Current opinion in cervix carcinoma. Clin Transl Oncol 2011; 13:378-84. [DOI: 10.1007/s12094-011-0671-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ferrigno R, Santos A, Martins LC, Weltman E, Chen MJ, Sakuraba R, Lopes CP, Cruz JC. Comparison of conformal and intensity modulated radiation therapy techniques for treatment of pelvic tumors. Analysis of acute toxicity. Radiat Oncol 2010; 5:117. [PMID: 21156076 PMCID: PMC3009969 DOI: 10.1186/1748-717x-5-117] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 12/14/2010] [Indexed: 12/04/2022] Open
Abstract
Background This retrospective analysis reports on the comparative outcome of acute gastrointestinal (GI) and genitourinary (GU) toxicities between conformal radiation therapy (CRT) and intensity modulated radiation therapy (IMRT) techniques in the treatment of patients with pelvic tumors. Methods From January 2002 to December 2008, 69 patients with pelvic tumors underwent whole pelvic CRT and 65 underwent whole pelvic IMRT to treat pelvic lymph nodes and primary tumor regions. Total dose to the whole pelvis ranged from 50 to 50.4 Gy in 25 to 28 daily fractions. Chemotherapy (CT) regimen, when employed, was based upon primary tumor. Acute GI and GU toxicities were graded by RTOG/EORTC acute radiation morbidity criteria. Results Absence of GI symptoms during radiotherapy (grade 0) was more frequently observed in the IMRT group (43.1% versus 8.7; p < 0.001) and medication for diarrhea (Grade 2) was more frequently used in the CRT group (65.2% versus 38.5%; p = 0.002). Acute GI grade 1 and 3 side effects incidence was similar in both groups (18.5% versus 18.8%; p = 0.95 and 0% versus 7.2%; p = 0.058, respectively). Incidence of GU toxicity was similar in both groups (grade 0: 61.5% versus 66.6%, p = 0.54; grade 1: 20% versus 8.7%, p = 0.06; grade 2: 18.5% versus 23.5%, p = 0.50 and grade 3: 0% versus 1.5%, p > 0.99). Conclusions This comparative case series shows less grade 2 acute GI toxicity in patients treated with whole pelvic IMRT in comparison with those treated with CRT. Incidence of acute GU toxicity was similar in both groups.
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Affiliation(s)
- Robson Ferrigno
- Department of Radiation Oncology, Hospital Israelita Albert Einstein, Av, Albert Einstein, 627, São Paulo-SP-05651-901-Brazil.
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Hsieh CH, Wei MC, Hsu YP, Chong NS, Chen YJ, Hsiao SM, Hsieh YP, Wang LY, Shueng PW. Should helical tomotherapy replace brachytherapy for cervical cancer? Case report. BMC Cancer 2010; 10:637. [PMID: 21092235 PMCID: PMC3001446 DOI: 10.1186/1471-2407-10-637] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 11/23/2010] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) administered via a helical tomotherapy (HT) system is an effective modality for treating lung cancer and metastatic liver tumors. Whether SBRT delivered via HT is a feasible alternative to brachytherapy in treatment of locally advanced cervical cancer in patients with unusual anatomic configurations of the uterus has never been studied. CASE PRESENTATION A 46-year-old woman presented with an 8-month history of abnormal vaginal bleeding. Biopsy revealed squamous cell carcinoma of the cervix. Magnetic resonance imaging (MRI) showed a cervical tumor with direct invasion of the right parametrium, bilateral hydronephrosis, and multiple uterine myomas. International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical cancer was diagnosed. Concurrent chemoradiation therapy (CCRT) followed by SBRT delivered via HT was administered instead of brachytherapy because of the presence of multiple uterine myomas with bleeding tendency. Total abdominal hysterectomy was performed after 6 weeks of treatment because of the presence of multiple uterine myomas. Neither pelvic MRI nor results of histopathologic examination at X-month follow-up showed evidence of tumor recurrence. Only grade 1 nausea and vomiting during treatment were noted. Lower gastrointestinal bleeding was noted at 14-month follow-up. No fistula formation and no evidence of haematological, gastrointestinal or genitourinary toxicities were noted on the most recent follow-up. CONCLUSIONS CCRT followed by SBRT appears to be an effective and safe modality for treatment of cervical cancer. Larger-scale studies are warranted.
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Affiliation(s)
- Chen-Hsi Hsieh
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei, Taiwan
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Hsieh CH, Wei MC, Hsu YP, Chong NS, Chen YJ, Hsiao SM, Hsieh YP, Wang LY, Shueng PW. Should helical tomotherapy replace brachytherapy for cervical cancer? Case report. BMC Cancer 2010. [PMID: 21092235 DOI: 10.1186/1471-2407-10-637.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) administered via a helical tomotherapy (HT) system is an effective modality for treating lung cancer and metastatic liver tumors. Whether SBRT delivered via HT is a feasible alternative to brachytherapy in treatment of locally advanced cervical cancer in patients with unusual anatomic configurations of the uterus has never been studied. CASE PRESENTATION A 46-year-old woman presented with an 8-month history of abnormal vaginal bleeding. Biopsy revealed squamous cell carcinoma of the cervix. Magnetic resonance imaging (MRI) showed a cervical tumor with direct invasion of the right parametrium, bilateral hydronephrosis, and multiple uterine myomas. International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical cancer was diagnosed. Concurrent chemoradiation therapy (CCRT) followed by SBRT delivered via HT was administered instead of brachytherapy because of the presence of multiple uterine myomas with bleeding tendency. Total abdominal hysterectomy was performed after 6 weeks of treatment because of the presence of multiple uterine myomas. Neither pelvic MRI nor results of histopathologic examination at X-month follow-up showed evidence of tumor recurrence. Only grade 1 nausea and vomiting during treatment were noted. Lower gastrointestinal bleeding was noted at 14-month follow-up. No fistula formation and no evidence of haematological, gastrointestinal or genitourinary toxicities were noted on the most recent follow-up. CONCLUSIONS CCRT followed by SBRT appears to be an effective and safe modality for treatment of cervical cancer. Larger-scale studies are warranted.
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Affiliation(s)
- Chen-Hsi Hsieh
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei, Taiwan
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Du XL, Sheng XG, Jiang T, Yu H, Yan YF, Gao R, Lu CH, Li QS. Intensity-modulated radiation therapy versus para-aortic field radiotherapy to treat para-aortic lymph node metastasis in cervical cancer: prospective study. Croat Med J 2010; 51:229-36. [PMID: 20564766 DOI: 10.3325/cmj.2010.51.229] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To compare dosimetry, efficacy, and toxicity of intensity-modulated radiation therapy (IMRT) with para-aortic field radiotherapy in patients with para-aortic lymph node (PALN) metastasis of cervical cancer. METHODS This prospective study examined 60 patients with cervical cancer with PALN metastasis who underwent whole-pelvis radiotherapy followed by brachytherapy between November 1, 2004 and May 31, 2008. After 3 cycles of chemotherapy, patients were serially allocated into two groups and treated with IMRT or para-aortic field RT at doses of 58-68 Gy and 45-50 Gy, respectively. Treatment response was evaluated and toxicities were assessed. Patients in the IMRT group were treated with both para-aortic field RT and IMRT in order to compare the exposure dose of organs at risk. RESULTS In the IMRT group, the mean dose delivered to the planning target volume was 67.5 Gy. At least 99% of the gross tumor volume received effective coverage and radical dose (median, 63.5 Gy; range, 54.5-66) during treatment. IMRT plans yielded better dose conformity to the target and better sparing of the spinal cord and small intestine than para-aortic field RT. The IMRT patients experienced less acute and chronic toxicities. The IMRT group also had higher 2- and 3-year survival rates than the para-aortic RT group (2-year, 58.8% vs 25.0%, P = 0.019; 3-year, 36.4% vs 15.6%, P = 0.016). However, no significant difference was found in 1-year survival (67.7% vs 51.3%, P =0.201). The median survival in the IMRT group was 25 months (range, 3 to 37 months). The actuarial overall survival, disease-free survival, and locoregional control rates at 2 years were 67%, 77%, and 88%, respectively, in the IMRT group. CONCLUSIONS IMRT provides better clinical outcomes than para-aortic field radiotherapy in patients with PALN metastasis. However, cervical local and distal recurrence remain a problem. Long-term follow-up and studies involving more patients are needed to confirm our results.
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Affiliation(s)
- Xue-lian Du
- Xiu-gui Sheng, Department of Gynecologic Oncology, Shandong Tumor Hospital and Institute, Jinan 250117, People's Republic of China
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Stewart J, Lim K, Kelly V, Xie J, Brock KK, Moseley J, Cho YB, Fyles A, Lundin A, Rehbinder H, Löf J, Jaffray D, Milosevic M. Automated weekly replanning for intensity-modulated radiotherapy of cervix cancer. Int J Radiat Oncol Biol Phys 2010; 78:350-8. [PMID: 20832664 DOI: 10.1016/j.ijrobp.2009.07.1699] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 06/19/2009] [Accepted: 07/22/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE The adoption of intensity-modulated radiotherapy (IMRT) to treat cervical malignancies has been limited in part by complex organ and tumor motion during treatment. This study explores the limits of a highly adaptive, small-margin treatment scenario to accommodate this motion. In addition, the dosimetric consequences of organ and tumor motion are modeled using a combination of deformable registration and fractional dose accumulation techniques. METHODS AND MATERIALS Thirty-three cervix cancer patients had target volumes and organs-at-risk contoured on fused, pretreatment magnetic resonance-computed tomography images and weekly magnetic resonance scans taken during treatment. The dosimetric impact of interfraction organ and target motion was compared for two hypothetical treatment scenarios: a 3-mm margin plan with no replanning, and a 3-mm margin plan with an automated replan performed on the updated weekly patient geometry. RESULTS Of the 33 patients, 24 (73%) met clinically acceptable target coverage (98% of the clinical target volume receiving at least 95% of the prescription dose) using the 3-mm margin plan without replanning. The range in dose to 98% of the clinical target volume across all patients was 7.9% of the prescription dose if no replanning was performed. After weekly replanning, this range was tightened to 2.6% of the prescription dose and all patients met clinically acceptable target coverage while maintaining organ-at-risk dose sparing. CONCLUSIONS The dosimetric impact of anatomical motion underscores the challenges of applying IMRT to treat cervix cancer. An appropriate adaptive strategy can ensure target coverage for small-margin IMRT treatments and maintain favorable organ-at-risk dose sparing.
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Affiliation(s)
- James Stewart
- Princess Margaret Hospital/Ontario Cancer Institute, University Health Network, Toronto, Canada
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Park HC, Shimizu S, Yonesaka A, Tsuchiya K, Ebina Y, Taguchi H, Katoh N, Kinoshita R, Ishikawa M, Sakuragi N, Shirato H. High dose three-dimensional conformal boost using the real-time tumor tracking radiotherapy system in cervical cancer patients unable to receive intracavitary brachytherapy. Yonsei Med J 2010; 51:93-9. [PMID: 20046520 PMCID: PMC2799970 DOI: 10.3349/ymj.2010.51.1.93] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 02/26/2009] [Accepted: 04/08/2009] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The purpose of this study is to evaluate the clinical results of treatment with a high dose of 3-dimensional conformal boost (3DCB) using a real-time tracking radiation therapy (RTRT) system in cervical cancer patients. MATERIALS AND METHODS Between January 2001 and December 2004, 10 patients with cervical cancer were treated with a high dose 3DCB using RTRT system. Nine patients received whole pelvis radiation therapy (RT) with a median dose of 50 Gy (range, 40-50 Gy) before the 3DCB. The median dose of the 3DCB was 30 Gy (range, 25-30 Gy). Eight patients received the 3DCB twice a week with a daily fraction of 5 Gy. The determined endpoints were tumor response, overall survival, local failure free survival, and distant metastasis free survival. The duration of survival was calculated from the time of the start of radiotherapy. RESULTS All patients were alive at the time of analysis and the median follow-up was 17.6 months (range, 4.9-27.3 months). Complete response was achieved in nine patients and one patient had a partial response. The 1- and 2-year local failure free survival was 78.8% and 54%, respectively. The 1- and 2-year distant metastasis free survival was 90% and 72%, respectively. Late toxicity of a grade 2 rectal hemorrhage was seen in one patient. A subcutaneous abscess was encountered in one patient. CONCLUSION The use of the high dose 3DCB in the treatment of cervical cancer is safe and feasible where intracavitary brachytherapy (ICBT) is unable to be performed. The escalation of the 3DCB dose is currently under evaluation.
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Affiliation(s)
- Hee Chul Park
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Shinichi Shimizu
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akio Yonesaka
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazuhiko Tsuchiya
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yasuhiko Ebina
- Department of Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Taguchi
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Norio Katoh
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Rumiko Kinoshita
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masayori Ishikawa
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Noriaki Sakuragi
- Department of Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroki Shirato
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Vandecasteele K, De Neve W, De Gersem W, Delrue L, Paelinck L, Makar A, Fonteyne V, De Wagter C, Villeirs G, De Meerleer G. Intensity-modulated arc therapy with simultaneous integrated boost in the treatment of primary irresectable cervical cancer. Treatment planning, quality control, and clinical implementation. Strahlenther Onkol 2009; 185:799-807. [PMID: 20013089 DOI: 10.1007/s00066-009-1986-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 09/30/2009] [Indexed: 12/25/2022]
Abstract
PURPOSE To report on the planning procedure, quality control, and clinical implementation of intensity-modulated arc therapy (IMAT) delivering a simultaneous integrated boost (SIB) in patients with primary irresectable cervix carcinoma. PATIENTS AND METHODS Six patients underwent PET-CT (positron emission tomography-computed tomography) and MRI (magnetic resonance imaging) before treatment planning. Prescription (25 fractions) was (1) a median dose (D(50)) of 62, 58 and 56 Gy to the primary tumor (GTV_cervix), primary clinical target volume (CTV_cervix) and its planning target volume (PTV_cervix), respectively; (2) a D(50) of 60 Gy to the PET-positive lymph nodes (GTV_nodes); (3) a minimal dose (D(98)) of 45 Gy to the planning target volume of the elective lymph nodes (PTV_nodes). IMAT plans were generated using an anatomy-based exclusion tool with the aid of weight and leaf position optimization. The dosimetric delivery of IMAT was validated preclinically using radiochromic film dosimetry. RESULTS Five to nine arcs were needed to create valid IMAT plans. Dose constraints on D(50) were not met in two patients (both GTV_cervix: 1 Gy and 3 Gy less). D(98) for PTV_nodes was not met in three patients (1 Gy each). Film dosimetry showed excellent gamma evaluation. There were no treatment interruptions. CONCLUSION IMAT allows delivering an SIB to the macroscopic tumor without compromising the dose to the elective lymph nodes or the organs at risk. The clinical implementation is feasible.
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Guckenberger M, Wulf J, Thalheimer A, Wehner D, Thiede A, Müller G, Sailer M, Flentje M. Prospective phase II study of preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy--long-term results. Radiat Oncol 2009; 4:67. [PMID: 20025752 PMCID: PMC2806295 DOI: 10.1186/1748-717x-4-67] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 12/21/2009] [Indexed: 12/20/2022] Open
Abstract
Background To evaluate clinical outcome after preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy and adjuvant chemotherapy for pathological stage UICC ≥ II. Methods 118 patients (median age 64 years; male : female ratio 2.5 : 1) with pathological proven rectal cancer (clinical stage II 50%, III 41.5%, IV 8.5%) were treated preoperatively with twice daily radiotherapy of 2.9 Gy single fraction dose to a total dose of 29 Gy; surgery was performed immediately in the following week with total mesorectal excision (TME). Adjuvant 5-FU based chemotherapy was planned for pathological stage UICC ≥ II. Results After low anterior resection (70%) and abdominoperineal resection (30%), pathology showed stage UICC I (27.1%), II (25.4%), III (37.3%) and IV (9.3%). Perioperative mortality was 3.4% and perioperative complications were observed in 22.8% of the patients. Adjuvant chemotherapy was given in 75.3% of patients with pathological stage UICC ≥ II. After median follow-up of 46 months, five-year overall survival was 67%, cancer-specific survival 76%, local control 92% and freedom from systemic progression 75%. Late toxicity > grade II was observed in 11% of the patients. Conclusions Preoperative short-course radiotherapy, total mesorectal excision and adjuvant chemotherapy for pathological stage UICC ≥ II achieved excellent local control and favorable survival.
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Patterns of local and nodal failure in malignant pleural mesothelioma after extrapleural pneumonectomy and photon-electron radiotherapy. J Thorac Oncol 2009; 4:746-50. [PMID: 19404212 DOI: 10.1097/jto.0b013e3181a5292c] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Multimodality therapy including extrapleural pneumonectomy (EPP), chemotherapy, and radiotherapy (RT) is often recommended for fit patients with early stage malignant pleural mesothelioma. Planning RT after an EPP is difficult due to the large target area, the high doses required to prevent recurrence, and the proximity of critical structures. We studied patterns of local and nodal recurrence in patients treated at our institution with EPP and RT, and whether advanced treatment planning techniques, such as intensity modulated radiotherapy (IMRT), could have been of potential benefit. METHODS From 1993 to 2008, 86 patients with malignant pleural mesothelioma underwent EPP followed by hemithoracic RT (median dose: 54 Gy). The RT technique included a combination of photons and electrons to maximize dose to the target, whereas minimizing dose to normal tissues. After treatment, patients were followed with serial imaging and patterns of local and nodal failure were studied. RESULTS Median follow-up time for 78 analyzed patients was 17 months. Eight percent were in stage I, 35% stage II, 55% stage III, and 2% stage IV. Ten percent of all patients developed late grade 3 pulmonary toxicity and no patient died of RT. Fifteen patients failed in local and/or nodal sites and did not have a distant component to their failure pattern. Of these 15 patients, 10 failed in regions of dose inhomogeneity and could have possibly benefited from IMRT. CONCLUSIONS The photon-electron technique was tolerable, but IMRT may provide better target coverage in some patients. IMRT's advantages must be balanced against the increased risk of fatal pulmonary toxicity.
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Beadle BM, Jhingran A, Salehpour M, Sam M, Iyer RB, Eifel PJ. Cervix regression and motion during the course of external beam chemoradiation for cervical cancer. Int J Radiat Oncol Biol Phys 2009; 73:235-41. [PMID: 18513882 DOI: 10.1016/j.ijrobp.2008.03.064] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 03/18/2008] [Accepted: 03/20/2008] [Indexed: 02/03/2023]
Abstract
PURPOSE To evaluate the magnitude of cervix regression and motion during external beam chemoradiation for cervical cancer. METHODS AND MATERIALS Sixteen patients with cervical cancer underwent computed tomography scanning before, weekly during, and after conventional chemoradiation. Cervix volumes were calculated to determine the extent of cervix regression. Changes in the center of mass and perimeter of the cervix between scans were used to determine the magnitude of cervix motion. Maximum cervix position changes were calculated for each patient, and mean maximum changes were calculated for the group. RESULTS Mean cervical volumes before and after 45 Gy of external beam irradiation were 97.0 and 31.9 cc, respectively; mean volume reduction was 62.3%. Mean maximum changes in the center of mass of the cervix were 2.1, 1.6, and 0.82 cm in the superior-inferior, anterior-posterior, and right-left lateral dimensions, respectively. Mean maximum changes in the perimeter of the cervix were 2.3 and 1.3 cm in the superior and inferior, 1.7 and 1.8 cm in the anterior and posterior, and 0.76 and 0.94 cm in the right and left lateral directions, respectively. CONCLUSIONS Cervix regression and internal organ motion contribute to marked interfraction variations in the intrapelvic position of the cervical target in patients receiving chemoradiation for cervical cancer. Failure to take these variations into account during the application of highly conformal external beam radiation techniques poses a theoretical risk of underdosing the target or overdosing adjacent critical structures.
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Affiliation(s)
- Beth M Beadle
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Conformal and intensity-modulated radiotherapy for cervical cancer. Clin Oncol (R Coll Radiol) 2008; 20:417-25. [PMID: 18558480 DOI: 10.1016/j.clon.2008.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 04/01/2008] [Accepted: 04/17/2008] [Indexed: 12/28/2022]
Abstract
Three-dimensional radiotherapy planning techniques, including conformal radiotherapy and intensity-modulated radiotherapy, have potential for improving outcomes in cervical cancer. Accurate target volume definition is essential in order to maximise normal tissue sparing while minimising the risk of a geographical miss. This reduction in toxicity provides the option of dose escalation, particularly with simultaneous integrated boost intensity-modulated radiotherapy. The evidence for the current use and potential applications of these techniques in the treatment of cervical cancer are discussed.
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Miles EF, Larrier NA, Kelsey CR, Hubbs JL, Ma J, Yoo S, Marks LB. Intensity-modulated radiotherapy for resected mesothelioma: the Duke experience. Int J Radiat Oncol Biol Phys 2008; 71:1143-50. [PMID: 18262369 DOI: 10.1016/j.ijrobp.2007.11.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 11/08/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE To assess the safety and efficacy of intensity-modulated radiotherapy (IMRT) after extrapleural pneumonectomy for malignant pleural mesothelioma. METHODS AND MATERIALS Thirteen patients underwent IMRT after extrapleural pneumonectomy between July 2005 and February 2007 at Duke University Medical Center. The clinical target volume was defined as the entire ipsilateral hemithorax, chest wall incisions, including drain sites, and involved nodal stations. The dose prescribed to the planning target volume was 40-55 Gy (median, 45). Toxicity was graded using the modified Common Toxicity Criteria, and the lung dosimetric parameters from the subgroups with and without pneumonitis were compared. Local control and survival were assessed. RESULTS The median follow-up after IMRT was 9.5 months. Of the 13 patients, 3 (23%) developed Grade 2 or greater acute pulmonary toxicity (during or within 30 days of IMRT). The median dosimetric parameters for those with and without symptomatic pneumonitis were a mean lung dose (MLD) of 7.9 vs. 7.5 Gy (p = 0.40), percentage of lung volume receiving 20 Gy (V(20)) of 0.2% vs. 2.3% (p = 0.51), and percentage of lung volume receiving 5 Gy (V(20)) of 92% vs. 66% (p = 0.36). One patient died of fatal pulmonary toxicity. This patient received a greater MLD (11.4 vs. 7.6 Gy) and had a greater V(20) (6.9% vs. 1.9%), and V(5) (92% vs. 66%) compared with the median of those without fatal pulmonary toxicity. Local and/or distant failure occurred in 6 patients (46%), and 6 patients (46%) were alive without evidence of recurrence at last follow-up. CONCLUSIONS With limited follow-up, 45-Gy IMRT provides reasonable local control for mesothelioma after extrapleural pneumonectomy. However, treatment-related pulmonary toxicity remains a significant concern. Care should be taken to minimize the dose to the remaining lung to achieve an acceptable therapeutic ratio.
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Affiliation(s)
- Edward F Miles
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Chan P, Dinniwell R, Haider MA, Cho YB, Jaffray D, Lockwood G, Levin W, Manchul L, Fyles A, Milosevic M. Inter- and intrafractional tumor and organ movement in patients with cervical cancer undergoing radiotherapy: a cinematic-MRI point-of-interest study. Int J Radiat Oncol Biol Phys 2007; 70:1507-15. [PMID: 18164850 DOI: 10.1016/j.ijrobp.2007.08.055] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 08/16/2007] [Accepted: 08/20/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE Internal tumor and organ movement is important when considering intensity-modulated radiotherapy for patients with cancer of the cervix because of the tight margins and steep dose gradients. In this study, the internal movement of the tumor, cervix, and uterus were examined using serial cinematic magnetic resonance imaging scans and point-of-interest analysis. METHODS AND MATERIALS Twenty patients with Stage IB-IVA cervical cancer underwent pelvic magnetic resonance imaging before treatment and then weekly during external beam radiotherapy. In each 30-min session, sequential T(2)-sagittal magnetic resonance imaging scans were obtained. The points of interest (cervical os, uterine canal, and uterine fundus) were traced on each image frame, allowing the craniocaudal and anteroposterior displacements to be measured. The mean displacements and trends were analyzed using mixed linear models. Prediction intervals were calculated to determine the internal target margins. RESULTS Large interscan motion was found for all three points of interest that was only partially explained by the variations in bladder and rectal filling. The intrascan motion was much smaller. Both inter- and intrascan motion was greatest at the fundus of the uterus, less along the canal, and least at the cervical os. The isotropic internal target margins required to encompass 90% of the interscan motion were 4 cm at the fundus and 1.5 cm at the os. In contrast, smaller margins of 1 cm and 0.45 cm, respectively, were adequate to encompass the intrascan motion alone. CONCLUSION Daily soft-tissue imaging with correction for interfractional motion or adaptive replanning will be important if the benefits of intensity-modulated radiotherapy are to be maximized in women with cervical cancer.
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Affiliation(s)
- Philip Chan
- Radiation Medicine Program, Princess Margaret Hospital/Ontario Cancer Institute, University Health Network, Toronto, ON, Canada
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Tran PT, Su Z, Lee P, Lavori P, Husain A, Teng N, Kapp DS. Prognostic factors for outcomes and complications for primary squamous cell carcinoma of the vagina treated with radiation. Gynecol Oncol 2007; 105:641-9. [PMID: 17363046 DOI: 10.1016/j.ygyno.2007.01.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 01/13/2007] [Accepted: 01/18/2007] [Indexed: 12/27/2022]
Abstract
PURPOSE To analyze the results of treatment and identify prognostic factors for primary squamous cell carcinoma (SCCA) of the vagina managed with radiotherapy at a single institution. MATERIALS AND METHODS Seventy-eight patients were analyzed in this retrospective series. Mean characteristics: follow-up 89 months; age 65 years (range 33-99); tumor size 3.8 cm (0.3-10); treatment hemoglobin 12.4 g/dl (range 8.7-14.4); and tumor dose 72 Gy (range 6-127). In addition, 49% of our cohort had a prior hysterectomy. The FIGO stage distribution: I (42%); II (29%); III (17%); and IVA/B (11%). Sixty-two percent of patients were treated with a combination of external beam radiation (EBRT) and brachytherapy, 22% with EBRT alone and 13% with brachytherapy alone. RESULTS Kaplan-Meier (KM) 5-year pelvic control, distant metastasis free survival and disease specific survival probabilities: stage I, 83%, 100%, and 92%; stage II, 76%, 95%, and 68%; stage III, 62%, 65%, and 44%; and stage IV, 30%, 18%, and 13%. On multivariate analysis: stage; treatment hemoglobin; and prior hysterectomy were prognostic for DSS (p<0.05). The KM 5-year grade 3/4 (G3/4) complication free estimate of our cohort was 84%. G3/4 complications: tumor size and tumor dose were independently predictive (p<0.05). CONCLUSIONS Radiotherapy as a single modality for early stage primary vaginal SCCA produces good results. Advanced stage disease necessitates a combined modality approach and/or new methods. Treatment Hg levels appear to be clinically significant and studies on correction of anemia during treatment are warranted.
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Affiliation(s)
- Phuoc T Tran
- Department of Radiation Oncology, Stanford Cancer Center, 875 Blake Wilbur Drive, Stanford, CA 94305, USA
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In response to Drs. Cameron and Cornes. Int J Radiat Oncol Biol Phys 2006. [DOI: 10.1016/j.ijrobp.2006.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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