A pilot study on concurrent platinum chemotherapy and intracavitary brachytherapy for locally advanced cancer of the uterine cervix

Concurrent chemotherapy with high-dose rate brachytherapy after treatment with chemoradiotherapy in cases of locally advanced carcinoma cervix: A study from rural area of Maharashtra, India

Aim

This study aims to evaluate the efficacy, feasibility, tolerability, and toxicity of concurrent chemotherapy and brachytherapy for locally advanced cervical carcinoma.

Materials and Methods

Forty patients of cervical carcinoma were included in this study. The study period ranges from October 2016 to September 2019. Patients were evaluated and treated as per the protocol: external beam radiotherapy (50 Gy in 25 fractions) and concurrent weekly chemotherapy with injection (Inj.) cisplatin (30 mg/m2) followed by high-dose rate brachytherapy (3 fractions of 7 Gy each) and concurrent chemotherapy Inj. cisplatin (30 mg/m2).

Results

Out of 40 patients enrolled in the study, 36 patients completed the treatment (17 Stage II and 19 Stage III). The incidence of Grade I and II skin toxicities were 78% and 10%, respectively. The incidence of genitourinary toxicities with respect to Grade I and II were 72% and 12%, respectively. There were Grade III hematological toxicities in two patients and the brachytherapy treatment was delayed for 4-6 days. The overall complete response was found in 28 (78%) patients, partial response in six (16.7%) patients, and progressive disease in two (5.6%) patients at 3 months of follow-up. On the last follow-up, 21 (58%) patients were disease-free and there was disease failure in seven patients (5 local recurrence and 2 with distant metastasis).

Conclusion

Brachytherapy with the addition of concurrent chemotherapy is effective and feasible with acceptable toxicity for advanced stages of carcinoma cervix. This study upholds an interesting approach that can be regarded as feasible and tolerable for cervical cancer patients.

Concurrent Chemo- Radiobrachytherapy with Cisplatin and Medium Dose Rate Intra- Cavitary Brachytherapy for Locally Advanced Uterine Cervical Cancer

Objective:

Cervical carcinoma is the third most common gynecologic cancer, after ovarian and uterine cancers in Iran. The aim of this study was to evaluate the efficacy (response rate) and toxicity of adding Medium Dose Rate (MDR) brachytherapy with concurrent chemotherapy to External Beam Radiotherapy (EBRT) for the treatment of locally advanced uterine cervical carcinoma.

Methods:

This phase I-II study was conducted in 2007-2008 at the cancer institute, Tehran University of Medical Sciences. Patients were treated with pelvic EBRT (50 Gy in 25 Fraction) with concomitant chemotherapy to obtain tumor shrinkage and permit optimal intra-cavitary placement. One week after the completion of EBRT, patients were treated by 12 Gy MDR Intra-cavitary brachytherapy for two periods of one day with a one week interval and concomitant platinum based chemotherapy. Response rate was evaluated by gynecologic physical examination and pelvic MRI +- GD within three months of treatment. Acute and late toxicity were assessed using Radiation Therapy Oncology Group criteria.

Results:

A total of 33 patients with locally advanced cervical cancer were treated according to the above described treatment protocol. The patients mean age was 53.2 (range 31–78) years. Three months after the completion of treatment, the complete clinical, pathologic and radiologic response rate according to WHO-criteria was 81.8% (27 patients). Six cases had a partial response or stable disease. After 48 months, average disease free survival periods were 45.1, 23.0, 33.4 and 8 months for stage IIB, IIIA, IIIB and IVA lesions (according to The International Federation of Gynecology and Obstetrics staging system). The most frequently observed side effects were leukopenia, anemia, proctitis, cystitis, nausea and vomiting (mostly grade 1 and 2).

Conclusion:

Concomitant brachytherapy and chemotherapy with platinum compounds can be well tolerated and is effective in the treatment of locally advanced cervical cancer.

Chemotherapy in the primary treatment of cervical carcinoma

Two major treatment modalities in cervical cancer include radiotherapy and surgery. In an attempt to improve the outcome, these modalities have been increasingly supplemented by chemotherapy. Chemotherapy can be combined with local therapies in various sequences. Of the two possible strategies using chemotherapy and radiotherapy (sequential or concomitant), the latter seems to be more effective. Platinum-based regimens applied concurrently with both definitive and post-operative radiation therapy were demonstrated to provide survival benefit in five of the six recently published randomised trials. The positive impact of chemotherapy added to radiotherapy has also been shown in a meta-analysis including 1894 patients in 19 randomised studies. This strategy, however, is accompanied by increased early toxicity. The benefit of chemotherapy applied prior to surgery remains debatable. The role of new cytotoxic and biological substances, as well as agents combating tumour hypoxia, warrants further clinical investigation.

Preventing vaginal stenosis after brachytherapy for gynaecological cancer: an overview of Australian practices

Despite advances in brachytherapy techniques in recent years, patients still experience a variety of treatment-related complications. Vaginal stenosis is a recognised toxicity of brachytherapy for the treatment of gynaecological cancer. It can result in long-term sexual dysfunction and painful vaginal examinations; however, it is generally accepted that it may be prevented by regular sexual intercourse or the use of vaginal dilators. The incidence of vaginal stenosis is variably reported in the literature, while preventative strategies and compliance are infrequently described and rarely evaluated. A telephone survey of radiation oncology centres in Australia was undertaken as a quality improvement activity to determine best practice for the use of vaginal dilators for the prevention of vaginal stenosis, by way of identifying similarities of practice. The results revealed a lack of consistency for all variables, including which patients are advised to use vaginal dilators, the time to initiate use, frequency of use, insertion time and duration of use. These findings suggest that current methods for preventing radiation-induced vaginal stenosis warrant formal evaluation in order to establish an evidence base for practice.

Phase I-II study of neoadjuvant chemoradiotherapy followed by radical surgery in locally advanced cervical cancer

The usefulness of neoadjuvant chemotherapy (NAC) regimens has been reported; however, the effect of NAC for advanced stages (especially stage III-IVA) is thought to be insufficient. We conducted a phase I-II study of neoadjuvant chemoradiotherapy consisting of intra-arterial (i.a.) infusion of carboplatin and intracavitary brachytherapy in patients with locally advanced cervical cancer to achieve the new NAC method. Sixteen eligible patients included those with previously untreated stage IIB, III or IVA cancer with bulky tumor. Brachytherapy using iridium-192 was performed with concurrent i.a. chemotherapy with carboplatin (200, 300 and 400 mg/m2). Treatment was repeated every 4 weeks for a total of two cycles. Both hematologic and non-hematologic toxicities were generally mild. Grade 4 hematologic toxicity was observed in 12.5% and there were no grade III or IV non-hematologic toxicities. The optimal dose of carboplatin was determined to be 400 mg/m2. Among 16 patients, six showed complete response (37.5%) and nine showed partial response (56.3%), for an overall response rate of 93.8%. All 15 responding patients underwent radical surgery with a pelvic lymphadenectomy and postoperative radiotherapy. The combination of brachytherapy and i.a. chemotherapy with carboplatin is a promising regimen for NAC in locally advanced cervical cancer.

Topotecan concomitant with primary brachytherapy radiation in patients with cervical carcinoma: a phase I trial

OBJECTIVE

The aim of this study was to assess the toxicity of concomitant topotecan and radiation therapy in a Phase I study. Primary treatment for cervical carcinoma usually consists of surgery or radiation, with chemotherapy used in a neoadjuvant or concomitant fashion. There are in vitro data to suggest that topotecan is a radiosensitizing agent.

METHODS

Six patients with cervical cancer were recruited to this study. All patients had completed whole pelvic radiation therapy and were scheduled for low-dose brachytherapy. The patients were administered topotecan IV during their low-dose brachytherapy. The initial dose of topotecan was 0.5 mg/m2/day for 5 days concomitant with low-dose brachytherapy for two brachytherapy applications.

RESULTS

Three patients were accrued to the initial dose level. No major toxicity was noted at this dose level. Three patients were treated at the 1.0 mg/m2/day dose level; however, significant toxicity was noted at this level. (Two patients experienced grade 4 and one a grade 3 hematologic toxicity).

CONCLUSION

Significant marrow toxicity was noted with concomitant topotecan and intracavitary radiation at 1.0 mg/m2/day. The maximum tolerated dose in this trial was 0.5 mg/m2/day for 5 days of topotecan concomitant with low-dose brachytherapy.