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Kuipers SC, Godart J, Corbeau A, Breedveld S, Mens JWM, de Boer SM, Nout RA, Hoogeman MS. Dosimetric impact of bone marrow sparing for robustly optimized IMPT for locally advanced cervical cancer. Radiother Oncol 2024; 195:110222. [PMID: 38471634 DOI: 10.1016/j.radonc.2024.110222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND PURPOSE To investigate the trade-off between bone marrow sparing (BMS) and dose to organs at risk (OARs) for intensity modulated proton therapy (IMPT) for women with locally advanced cervical cancer (LACC). MATERIALS AND METHODS Twenty LACC patients were retrospectively included. IMPT plans were created for each patient using automated treatment planning. These plans progressively reduced bone marrow mean doses by steps of 1 GyRBE, while constraining target coverage and conformality. The relation between bone marrow dose and bladder, small bowel, rectum, and sigmoid doses was evaluated. RESULTS A total of 140 IMPT plans were created. Plans without BMS had an average [range] bone marrow mean dose of 17.3 [14.7-21.6] GyRBE , which reduced to 12.0 [10.0-14.0] GyRBE with maximum BMS. The mean OAR dose [range] increased modestly for 1 GyRBE BMS: 0.2 [0.0 - 0.6] GyRBE for bladder, 0.3 [-0.2 - 0.7] GyRBE for rectum, 0.4 [0.1 - 0.8] GyRBE for small bowel, and 0.2 [-0.2 - 0.4] GyRBE for sigmoid. Moreover, for maximum BMS, mean OAR doses [range] escalated by 3.3 [0.1 - 6.7] GyRBE for bladder, 5.8 [1.8 - 12.4] GyRBE for rectum, 3.9 [1.6 - 5.9] GyRBE for small bowel, and 2.7 [0.6 - 5.9] GyRBE for sigmoid. CONCLUSION Achieving 1 GyRBE BMS for IMPT is feasible for LACC patients with limited dosimetric impact on other OARs. While further bone marrow dose reduction is possible for some patients, it may increase OAR doses substantially for others. Hence, we recommend a personalized approach when introducing BMS into clinical IMPT treatment planning to carefully assess individual patient benefits and risks.
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Affiliation(s)
- S C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands.
| | - J Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
| | - A Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J W M Mens
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - R A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
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Wark A, Gupta A, Meixner E, König L, Hörner-Rieber J, Forster T, Lang K, Ellerbrock M, Herfarth K, Debus J, Arians N. Bone Marrow Sparing by Intensity Modulated Proton Beam Therapy in Postoperative Irradiation of Gynecologic Malignancies. Technol Cancer Res Treat 2024; 23:15330338241252622. [PMID: 38845139 PMCID: PMC11159539 DOI: 10.1177/15330338241252622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/02/2024] [Accepted: 04/15/2024] [Indexed: 06/09/2024] Open
Abstract
Purpose: The aim of this matched-pair cohort study was to evaluate the potential of intensity-modulated proton therapy (IMPT) for sparring of the pelvic bone marrow and thus reduction of hematotoxicity compared to intensity-modulated photon radiotherapy (IMRT) in the setting of postoperative irradiation of gynaecological malignancies. Secondary endpoint was the assessment of predictive parameters for the occurrence of sacral insufficiency fractures (SIF) when applying IMPT. Materials and Methods: Two cohorts were analyzed consisting of 25 patients each. Patients were treated with IMPT compared with IMRT and had uterine cervical (n = 8) or endometrial cancer (n = 17). Dose prescription, patient age, and diagnosis were matched. Dosimetric parameters delivered to the whole pelvic skeleton and subsites (ilium, lumbosacral, sacral, and lower pelvis) and hematological toxicity were evaluated. MRI follow-up for evaluation of SIF was only available for the IMPT group. Results: In the IMPT group, integral dose to the pelvic skeleton was significantly lower (23.4GyRBE vs 34.3Gy; p < 0.001), the average V5Gy, V10Gy, and V20Gy were reduced by 40%, 41%, and 28%, respectively, compared to the IMRT group (p < 0.001). In particular, for subsites ilium and lower pelvis, the low dose volume was significantly lower. Hematotoxicity was significantly more common in the IMRT group (80% vs 32%; p = 0009), especially hematotoxicity ≥ CTCAE II (36% vs 8%; p = 0.037). No patient in the IMPT group experienced hematotoxicity > CTCAE II. In the IMPT cohort, 32% of patients experienced SIF. Overall SIF occurred more frequently with a total dose of 50.4 GyRBE (37.5%) compared to 45 GyRBE (22%). No significant predictive dose parameters regarding SIF could be detected aside from a trend regarding V50Gy to the lumbosacral subsite. Conclusion: Low-dose exposure to the pelvic skeleton and thus hematotoxicity can be significantly reduced by using IMPT compared to a matched photon cohort. Sacral insufficiency fracture rates appear similar to reported rates for IMRT in the literature.
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Affiliation(s)
- Antje Wark
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Anil Gupta
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Malte Ellerbrock
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Nathalie Arians
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
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Duranson A, Thevenet V, Guyon F, Babin G, Lebreton C, Renaud T, Gaillard AL, Dupuy Q, Bouleftour W, Magne N, Petit A. Pelvic insufficiency fractures after intensity modulated radiation therapy combined with chemotherapy for cervix carcinoma: Incidence and impact of bone mineral density. Clin Transl Radiat Oncol 2023; 41:100650. [PMID: 37441540 PMCID: PMC10334122 DOI: 10.1016/j.ctro.2023.100650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/15/2023] [Accepted: 06/04/2023] [Indexed: 07/15/2023] Open
Abstract
Background and Purpose The aim of this study was to evaluate the incidence and predictive factors of Pelvic Insufficiency Fractures (PIFs) occurring after Intensity Modulated Radiation Therapy (IMRT) combined with chemotherapy for locally advanced cervical cancer (CC). Material and methods Medical records of patients receiving radio-chemotherapy with IMRT between 2010 and 2020 for advanced CC were reviewed. PIFs were detected during follow-up on pelvic Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). The cumulative incidence rate of PIFs and its confidence interval were calculated at 2 and 5 years of follow-up. Pre-therapeutic Bone Mineral Density (BMD) (g/cm3) was evaluated on CT simulation for sacrum and the fourth lumbar (L4) vertebrae. Sacrum dosimetric parameters (V30Gy, V40Gy, D50%, Dmean) were analyzed. Results 136 patients were included. The median follow-up was 4.4 years. Median dose of D50% and V40Gy sacrum were 35.2 Gy (20.6-46.4) and 32.2% (7.2-73.4) respectively. The 2-year and 5-year cumulative incidence rates were 15.7% (95% CI: 9.88-22.71) and 22% (95% CI: 14.58-30.45) respectively. Median time interval between RT completion and PIFs' detection was 11.5 months (IQR: 7.4-22.3). Univariate analysis showed that older age (p < 0.01), postmenopausal status at baseline (p < 0.01), and lower sacral and spinal BMD at baseline (respectively p < 0.001 and p < 0.01) were significantly associated to all sites of PIFs, and lower sacral BMD with sacral fractures (p < 0.001). Conclusion Post-IMRT PIFs were detected in 18.4% of patients with locally advanced CC. Individual predisposing factors as older age, postmenopausal status, decreased bone density on the CT simulation were mainly predictive.
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Affiliation(s)
- Agathe Duranson
- Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Vincent Thevenet
- Department of Statistics, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Frédéric Guyon
- Department of Surgery, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Guillaume Babin
- Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Coriolan Lebreton
- Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Tiphaine Renaud
- Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Anne-Lise Gaillard
- Department of Diagnostic Radiology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Quentin Dupuy
- Department of Medical Physics, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Wafa Bouleftour
- Department of Medical Oncology, North Hospital, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Nicolas Magne
- Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
- Cellular and Molecular Radiobiology Laboratory, Lyon-Sud Medical School, Unité Mixte de Recherche CNRS5822/IP2I, University of Lyon, Lyon, France
| | - Adeline Petit
- Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
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Kuipers S, Godart J, Corbeau A, Sharfo AW, Breedveld S, Mens JW, de Boer S, Nout R, Hoogeman M. The impact of bone marrow sparing on organs at risk dose for cervical cancer: a Pareto front analysis. Front Oncol 2023; 13:1138433. [PMID: 37448523 PMCID: PMC10338058 DOI: 10.3389/fonc.2023.1138433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/05/2023] [Indexed: 07/15/2023] Open
Abstract
Background and purpose To quantify the increase in bladder and rectum dose of a bone marrow sparing (BMS) VMAT strategy for primary treatment of locally advanced cervical cancer (LACC). Materials and methods Twenty patients with stage IB-IVA cervical cancer were selected for this study. The whole Pelvic Bones (PB) was taken as substitute for bone marrow. For every patient, Pareto-optimal plans were generated to explore the trade-off between rectum, bladder, and PB mean dose. The PB mean dose was decreased in steps of 1 Gy. For each step, the increase in rectum and bladder mean dose was quantified. The increase in mean dose of other OAR compared to no BMS was constrained to 1 Gy. Results In total, 931 plans of 19 evaluable patients were analyzed. The average [range] mean dose of PB without BMS was 22.8 [20.7-26.2] Gy. When maximum BMS was applied, the average reduction in mean PB dose was 5.4 [3.0-6.8] Gy resulting in an average mean PB dose of 17.5 [15.8-19.8] Gy. For <1 Gy increase in both the bladder and the rectum mean dose, the PB mean dose could be decreased by >2 Gy, >3 Gy, >4 Gy, and >5 Gy for 19/19, 13/19, 5/19, and 1/19 patients, respectively. Conclusion Based on the comprehensive three-dimensional Pareto front analysis, we conclude that 2-5 Gy BMS can be implemented without a clinically relevant increase in mean dose to other OAR. If BMS is too dominant, it results in a large increase in mean dose to other OAR. Therefore, we recommend implementing moderate BMS for the treatment of LACC patients with VMAT.
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Affiliation(s)
- Sander Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Medical Physics and Informatics, HollandPTC, Delft, Netherlands
| | - Jérémy Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Medical Physics and Informatics, HollandPTC, Delft, Netherlands
| | - Anouk Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Abdul Wahab Sharfo
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sebastiaan Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jan Willem Mens
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stephanie de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Remi Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Medical Physics and Informatics, HollandPTC, Delft, Netherlands
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Chopade P, Chopra S. In Reply to Hasan et al. Int J Radiat Oncol Biol Phys 2023; 115:541-542. [PMID: 36621236 DOI: 10.1016/j.ijrobp.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Pradnya Chopade
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment and Education in Cancer Tata Memorial Centre (ACTREC), Homi Bhabha National Institute, Mumbai, India
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Arians N, Lindel K, Krisam J, Oelmann-Avendano JT, Meixner E, König L, Hoerner-Rieber J, Wark A, Forster T, Weykamp F, Lang K, Schneeweiss A, Ellerbrock M, Mielke T, Herfarth K, Debus J. Treatment Tolerability and Toxicity of Postoperative Proton Beam Therapy for Gynecologic Malignancies: Results of the Prospective Phase 2 APROVE-trial. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00012-3. [PMID: 36642110 DOI: 10.1016/j.ijrobp.2023.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
PURPOSE The APROVE study is a prospective one-arm phase-2 study investigating the safety and treatment tolerability of postoperative proton beam therapy in women with uterine cervical or endometrial cancer. In this analysis, we report the primary study endpoint of safety and treatment tolerability as well as toxicity rates and progression-free survival (PFS). METHODS AND MATERIALS 25 patients were treated with postoperative proton beam therapy with a total dose of 45 to 50.4 Gy (RBE) in 5 to 6 × 1.8 Gy (RBE) fractions weekly using active raster-scanning intensity modulated proton beam therapy (IMPT). Sequential or simultaneous platinum-based chemotherapy was administered if indicated. The primary endpoint was defined as the lack of any acute ≥grade 3 gastrointestinal (GI) or urogenital (GU) toxicity according to the Common Terminology Criteria for Adverse Events v 4.0 or premature treatment abortion. Secondary endpoints were clinical symptoms and toxicity, quality of life, and PFS. RESULTS All patients completed IMPT according to the protocol, with a median treatment duration of 43 days (range, 33 to 51 days). No patient developed gastrointestinal or genitourinary toxicity ≥grade 3, and the treatment tolerability rate was 100%. Therefore, the null hypothesis H0: Tolerability Rate ≤80% could be rejected in favor of the alternative hypothesis H1: Tolerability rate >80% using an exact binomial test with a one-sided significance level of α = 10% (one-sided P value P = .0059). The median follow-up time after the end of IMPT was 25.1 months (range, 20.2 to 50.3 months). 18 of 25 (75%) patients completed the study follow-up of 24 months. 7 patients had progressive disease. Kaplan-Meier-estimated mean PFS was 39.9 months (95% confidence interval: 33.37 to 46.5 months). CONCLUSIONS Postoperative IMPT is a safe treatment option for cervical and endometrial cancer patients, with only low-grade acute and late toxicities. Larger randomized trials are necessary to further assess the potential of IMPT and improve patient selection.
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Affiliation(s)
- Nathalie Arians
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany.
| | - Katja Lindel
- Municipal Hospital Karlsruhe, Department of Radiation Oncology, Karlsruhe, Germany
| | - Johannes Krisam
- Institute for Medical Biometry, Heidelberg University, Heidelberg, Germany
| | | | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Antje Wark
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Andreas Schneeweiss
- Division of Gynecologic Oncology, National Center for Tumor Diseases, Heidelberg, Germany
| | - Malte Ellerbrock
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Mielke
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Heidelberg, Germany
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Bukkems LJ, Jürgenliemk-Schulz IM, van der Leij F, Peters M, Gerestein CG, Zweemer RP, van Rossum PS. The impact of para-aortic lymph node irradiation on disease-free survival in patients with cervical cancer: A systematic review and meta-analysis. Clin Transl Radiat Oncol 2022; 35:97-103. [PMID: 35669003 PMCID: PMC9166370 DOI: 10.1016/j.ctro.2022.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background Patients with locally advanced cervical cancer without para-aortic lymph node metastases (PAO-LNM) at diagnosis who undergo concurrent chemoradiotherapy are at 4-11% risk of developing PAO-LNM during follow-up. Some studies suggest a beneficial influence of elective para-aortic radiotherapy (PAO-RT) on disease-free survival (DFS) in these patients. The aim of this study was to systematically review and meta-analyse literature on the impact of PAO-RT on DFS in cervical cancer patients. Methods A systematic search of PubMed/MEDLINE and EMBASE databases was performed. The analysis included intervention studies that reported on DFS in patients with cervical cancer who received chemotherapy and pelvic radiotherapy with or without PAO-RT. From each included study, relevant study characteristics and outcome data including the hazard ratio (HR) adjusted for potential confounders were extracted. An overall pooled adjusted hazard ratio (aHR) for DFS after PAO-RT versus no PAO-RT was calculated using a random-effects model. Results A total of 2,016 articles were evaluated. Eleven articles were included in the systematic review, of which 3 were appropriate for quantitative meta-analysis. Pooling of these 3 cohorts (including 1,113 patients) demonstrated a statistically significant association between PAO-RT and DFS (pooled aHR 0.87, 95% confidence interval: 0.79-0.97). No significant heterogeneity among reported aHRs was observed (I2 = 0.0%). Conclusions This meta-analysis suggests a modest but significant beneficial impact of elective para-aortic radiotherapy on DFS in patients with locally advanced cervical cancer who undergo concurrent chemoradiotherapy. This finding based on non-randomized studies provides an imperative for further investigation in prospective controlled trials.
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Affiliation(s)
- Leslie J.H. Bukkems
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis G. Gerestein
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ronald P. Zweemer
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter S.N. van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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