The Efficacy and Late Toxicities of Computed Tomography-based Brachytherapy with Intracavitary and Interstitial Technique in Advanced Cervical Cancer

Radiochemotherapy and interstitial brachytherapy for cervical cancer: clinical results and patient-reported outcome measures

OBJECTIVE

To evaluate clinical results and long-term patient-reported outcome measures (PROMs) on quality of life in cervical cancer patients following radiochemotherapy (RCT) and brachytherapy (BT) as definitive treatment.

MATERIALS AND METHODS

Between 2003 and 2023, a total of 132 patients with advanced cervical cancer were evaluated for possible treatment. Patients treated by postoperative RCT, palliative radiotherapy, and those treated for recurrent disease were excluded. Thus, 46 patients receiving standard RCT and BT as their curative treatment were included in this study. PROMs were assessed prospectively by patients' self-completion of the EORTC-QLQ-C30 and EORTC-QLQ-CX24 questionnaires.

RESULTS

Five-year overall survival (OS), distant metastases-free survival (DMFS), and pelvic tumor-free survival rates (PTFS) were 53%, 54%, and 83%, respectively. A significant impact on OS was seen for FIGO (International Federation of Gynecologic Oncology) stage (IIB-IIIA: 79% vs. IIIB-IVA: 33%, p = 0.015), for overall treatment time (OTT; 50-65 d: 64% vs. > 65 d: 38%, p = 0.004), and for rectal D2cc (≤ 73 Gy: 50% vs. > 73 Gy: 38%, p = 0.046). The identical parameters were significantly associated with DMFS (FIGO stage: p = 0.012, OTT: p = 0.008, D2cc: p = 0.024). No parameters with a significant influence on PTFS were seen. In multivariate analysis, an impact of FIGO stage on OS (p = 0.05) and DMFS (p = 0.014) was detected, and of rectal D2cc on DMFS (p = 0.031). The overall QoL score was 63/100. Cognitive function was the least impaired (84/100), while role functioning was the worst (67/100). On the symptom scale, insomnia (46/100), fatigue (41/100), dyspnea (32/100), pain (26/100), and financial difficulties (25/100) were scored the worst. According to EORTC-QLQ-CX24, peripheral neuropathy (36/100) and lymphedema (32/100) occurred most frequently. Impaired sexual/vaginal functioning (32/100) and body image (22/100) were also frequently recorded.

CONCLUSION

In patients with advanced cervical cancer, a combination of RCT and BT remains an excellent treatment option. In terms of patient-reported long-term quality of life, specific support is needed to alleviate symptoms including lymphedema, peripheral neuropathy, and impaired sexual activity.

High-dose-rate brachytherapy in uterine cervix carcinoma: a comparison of dosimetry and clinical outcomes among three fractionation schedules

Background

To assess the differences among three dose-fractionation schedules of image-guided adaptive brachytherapy (IGABT) in cervical squamous cell carcinoma (CSCC) by comparing the dosimetry and clinical outcomes.

Methods

Forty-five patients with CSCC who underwent chemoradiotherapy and IGABT were retrospectively enrolled and divided into three groups based on their dose-fractionation schedules of brachytherapy as: Group-5.5 (5.5 Gy × 6 fractions), Group-6.0 (6.0 Gy × 5 fractions), and Group-7.0 (7.0 Gy × 4 fractions). The analyzed dose-volume histogram parameters included D90% and D98% of the high-risk clinical target volume (HR-CTV), D90% and D98% of intermediate-risk clinical target volume (IR-CTV), and D0.1cc and D2cc of the organs-at-risk (OARs, namely the bladder, rectum, sigmoid and small intestine). Furthermore, the therapeutic efficacy and late toxicities were also compared among the three groups.

Results

The doses of HR-CTV and IR-CTV in Group-5.5 were found to be the highest among the three groups, followed by those in Group-6.0. Significant differences were found for the doses of HR-CTV between Group-5.5 and the other groups. There were no significant differences in the bladder, sigmoid and small intestine dose among the three groups. However, Group-6.0 yielded the lowest rectum received doses, with a significant difference in D0.1cc being detected between Group-6.0 and Group-5.5. The median follow-up time was 30.08 months [range, 6.57-46.3]. The numbers of patients with complete response in Group-5.5, Group-6.0 and Group-7.0 were 13, 14 and 14, respectively (P > 0.05). In regard to the toxicitiy, the incidence of radiation cystitis and proctitis in Group-6.0 was lower than that in Group-5.5 and Group-7.0 (P > 0.05).

Conclusions

The dose-fractionation schedule of 6.0 Gy × 5 fractions provided the most beneficial effects with relatively low OARs doses, suggesting that this dose-fractionation schedule should be prioritized in the clinical application of brachytherapy in cervical cancer.

The safety and efficacy of volumetric modulated Arc therapy combined with computer tomography-guided adaptive brachytherapy for locally advanced cervical cancer: a single institution experience

BACKGROUND

Volumetric modulated arc therapy (VMAT) is a novel form of IMRT, which can deliver more accurate dose distribution and shorten treatment time. Compared to MRI-guided adaptive brachytherapy, which is recommended as gold standard imaging for cervical cancer contours, CT-guided adaptive brachytherapy (CTGAB) is more available, more widespread, and more affordable in many centers. This study aims to retrospectively analyze the efficacy and the safety of VMAT combined with CTGAB for patients with locally advanced cervical cancer.

METHODS AND MATERIALS

This study retrospectively analyzed 102 patients with locally advanced cervical cancer who underwent VMAT and CTGAB. Clinical outcomes including local control (LC), overall survival (OS) and progression-free survival (PFS), tumor response to treatment evaluated by the Response Evaluation Criteria in Solid Tumors (RECIST) (version 1.1), and toxicities including gastrointestinal toxicity, urinary toxicity and hematologic toxicity evaluated by the Common Terminology Criteria for Adverse Events (CTCAE) (version 5.0) were analyzed. The Kaplan-Meier method was used to calculate LC, OS, and PFS.

RESULTS

Median follow-up time was 19 months. Complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) occurred in 68 (66.7%), 24 (23.5%), 4 (3.92%), and 6 (5.88%), respectively. The 2-year and 3-year OS were 89.6% and 83%, respectively. The 2-year and 3-year PFS were 84.2% and 74.3%, respectively. The 2-year and 3-year LC were 90.1% and 79.3%, respectively. The average cumulative D2cm3 in the rectum, the bladder, the colon, and the small intestine were 78.07 (SD: 0.46) Gy, 93.20 (SD: 0.63) Gy, 63.55 (SD: 1.03) Gy and 61.07 (SD: 0.75) Gy, respectively. The average cumulative D90% of the high-risk clinical target volume (HR-CTV) was 92.26 (SD: 0.35) Gy. Grade ≥ 3 gastrointestinal and urinary toxicities occurred in 4.9% and 0.98%, respectively. 1.96% of patients were observed grade ≥ 4 gastrointestinal toxicities and none of the patients observed grade ≥ 4 urinary toxicities.

CONCLUSION

VMAT combined with CTGAB for locally advanced cervical cancer was an effective and safe treatment method, which showed satisfactory LC, OS, PFS, and acceptable toxicities.

Management and long-term clinical outcomes of patients with stage IVA cervical cancer with bladder involvement

OBJECTIVE

To describe the long-term outcomes of patients with stage IVA cervical cancer, a rare and deadly disease for which long-term toxicity data are scarce, to guide clinician counseling and survivorship support.

METHODS

In a retrospective review of a prospectively maintained database, we identified 76 patients with stage IVA cervical cancer with biopsy- or MRI-proven bladder mucosal involvement who received definitive radiotherapy (external beam radiotherapy [EBRT] alone or EBRT plus brachytherapy) with or without chemotherapy at our institution between 2000 and 2020. We used Kaplan-Meier modeling to estimate recurrence-free survival (RFS) and overall survival (OS) and used proportional hazard modeling to identify clinical variables associated with recurrence or survival. We performed actuarial competing risk modeling for severe late toxicity (grades 3 to 5, occurring >6 months of follow-up) and vesicovaginal fistulae (VVF), censoring for pelvic recurrence and death, and made comparisons between potential predictors using Gray's test and binary logistic regression.

RESULTS

The median follow-up time was 76 months (interquartile range 58-91). The median OS duration was 35 months (range, 18-not reached), and the 2- and 5-year OS rates were 53.6% and 40.9%, respectively. OS and RFS did not differ significantly between patients who received EBRT alone (N = 18) or EBRT plus brachytherapy (N = 49). Current smoking was a strong predictor of severe late toxicity, whose incidence was 14% at 2 years and 17% at 10 years. The VVF incidence was 24% at 2 years and 32% at 10 years.

CONCLUSION

Patients with stage IVA cervical cancer, even those who receive EBRT alone, can have long-term survival. These patients should be followed closely for late radiation-related toxicity.

Analysis of nutritional risk, skeletal muscle depletion, and lipid metabolism phenotype in acute radiation enteritis

BACKGROUND

Radiation enteritis, which often occurs during radiation-induced acute intestinal symptoms (RIAIS), is the most common and important complication during radiotherapy for cervical cancer. RIAIS caused by abdominal and pelvic radiotherapy will affect nutrient intake, digestion, absorption, and metabolism, leading to malnutrition or poorer nutritional status. In patients with malignant tumors, malnutrition can adversely affect the curative effect and response of radiotherapy by reducing radiosensitivity, affecting the precision of radiotherapy placement and increasing the incidence of radiotherapy-related adverse reactions.

AIM

To analyze nutritional risk, skeletal muscle depletion, and lipid metabolism phenotype in acute radiation enteritis.

METHODS

Fifty patients with cervical cancer received external beam radiotherapy, and 15 patients received brachytherapy after external beam radiotherapy. Body weight, body composition parameters, nutritional risk screening (NRS) 2002 score, and blood biochemical indices of patients with cervical cancer during periradiation were tested by a one-way repeated measures analysis of variance. Metabolomics analysis was used to identify characteristic lipid metabolism pathways. Clinical factors that affect linoleic acid changes were screened using the generalized evaluation equation.

RESULTS

Among the 50 patients, 37 had RIAIS, including 34 patients with grade 1-2 RIAIS and 3 patients with grade 3 RIAIS. The NRS 2002 score of patients who underwent cervical cancer radiotherapy continued to increase during the periradiation period, and 42 patients who underwent cancer radiotherapy had nutritional deficits (NRS 2002 score ≥ 3 points) at the end of radiotherapy. Correlation analyses revealed that body weight and body mass index changes were closely associated with body fat content (R2 = 0.64/0.51). The results of the univariate analysis showed that radiotherapy time, percentage reduction of serum albumin, and percentage reduction of serum prealbumin were the key factors affecting skeletal muscle exhaustion (P < 0.05). Metabolomic analysis of fecal supernatants of cervical cancer patients during the periradiation period revealed the involvement of linoleic acid, cholic acid, arachidonic acid, and N-acetyl-L-benzene alanine in the metabolic pathway of linoleic acid.

CONCLUSION

Cervical cancer radiotherapy patients faced nutritional risks, decreased serum albumin synthesis, and increased risk of skeletal muscle exhaustion. Linoleic acid was a biomarker of high nutritional risk.

Locally advanced cervical cancer: how the improvement in techniques in external beam radiotherapy and brachytherapy impacts on survival outcomes and long-term toxicities

BACKGROUND

Platinum-based chemoradiotherapy and brachytherapy are the standard treatment for locally advanced cervical cancer. Reported long-term outcomes for treated with both IMRT and 3D-Image-guided-adaptive brachytherapy are lacking.

METHODS

This retrospective study included 165 patients with FIGO Stage IB-IVB cervical cancer, treated with chemoradiotherapy in combination with brachytherapy. External beam radiotherapy was delivered as IMRT/VMAT/TOMO helical or 3DCRT. The intracavitary brachytherapy treatment (ICBT) was performed using two different planning system (with or without optimization).

RESULTS

Among the patient subgroups, comprising those who received IMRT/VMAT/Tomo helical and 3DCRT, as well as those who underwent ICBT planning optimization and those who did not, homogeneity was observed in terms of age, performance status, T stage, N status, TNM stage, and histology. With a median follow-up time of 60.5 months, the 5-year overall survival (OS) in the 3DCRT and IMRT groups was 74.9% and 92.8%, respectively (p = 0.033). The 5-year OS in the ICBT planning optimization group was 93.7%, compared to 75% in the non-optimization group (p = 0.014). Regarding late radiation toxicities, patients in the IMRT group had a lower incidence of chronic rectal toxicity compared to those in the 3DCRT group (6.5% vs. 34.1%, p = 0.001). The group with ICBT planning optimization had a lower incidence of late urinary toxicities (10.4%) compared to the non-optimized ICBT planning group (18.2%, p = 0.012). Similarly, the ICBT planning optimization group had a lower incidence of late rectal toxicity (6.5% with 80% grade 1 and 20% grade 2) compared to the non-optimized ICBT planning group (34.1%, p = 0.001).

CONCLUSION

In this series, the group of patients receiving optimized ICBT had an advantage in terms of OS and CSS suggesting that the use of new Treatment Planning Systems associated with 3D imaging, improves the long-term survival. Additionally, a significant reduction in late rectal and urinary toxicity has been observed.

Simultaneous Integrated Boost for Dose Escalation in Node-Positive Cervical Cancer: 5-Year Experience in a Single Institution

This study retrospectively evaluates clinical outcomes of dose escalation to involved nodes using volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) for node-positive locally advanced cervical cancer (LACC) at a single institution. Consecutive patients with node-positive LACC (FIGO2018 IIIC1-IVA) who received definitive chemoradiotherapy by VMAT 45 Gy in 25 fractions with SIB to 55-57.5 Gy, followed by magnetic resonance image-guided adaptive brachytherapy (IGABT) between 2018 and 2022 were identified. A standardized strategy regarding nodal boost delivery and elective para-aortic (PAO) irradiation was employed. Primary endpoints were involved nodal control (INC) and regional nodal control (RNC). Secondary endpoints were pelvic control (PC), locoregional control (LRC), disease-free survival (DFS), overall survival (OS), failure pattern, and radiotherapy-related toxicities. A total of 234 involved nodes (182 pelvic and 52 PAO) in 54 patients, with a median of 3 involved nodes per patient (range 1-16), were analyzed. After a median follow-up of 19.6 months, excellent INC was achieved, with four (2%) boost-volume failures occurring in three patients. The 2-year actuarial RNC, PC, LRC, DFS, and OS were 93%, 87%, 87%, 78%, and 85%, respectively. Adenocarcinoma histology was associated with worse RNC (p = 0.02) and OS (p = 0.04), whereas the primary tumor maximum standardized uptake value (SUVmax) was associated with worse PC (p = 0.04) and LRC (p = 0.046) on univariate analysis. The incidence of grade ≥3 acute and late radiotherapy-related toxicity were 2% and 4%, respectively. Treatment of node-positive LACC with VMAT with SIB allows safe and effective dose escalation. The 5-year local experience demonstrated excellent treatment outcomes without additional toxicity.

Comparative Analysis of 60Co and 192Ir Sources in High Dose Rate Brachytherapy for Cervical Cancer

High-dose-rate (HDR) brachytherapy (BT) is an essential treatment for cervical cancer, one of the most prevalent gynecological malignant tumors. In HDR BT, high radiation doses can be delivered to the tumor target with the minimum radiation doses to organs at risk. Despite the wide use of the small HDR 192Ir source, as the technique has improved, the HDR 60Co source, which has the same miniaturized geometry, has also been produced and put into clinical practice. Compared with 192Ir (74 days), 60Co has a longer half-life (5.3 years), which gives it a great economic advantage for developing nations. The aim of the study was to compare 60Co and 192Ir sources for HDR BT in terms of both dosimetry and clinical treatment. The results of reports published on the use of HDR BT for cervical cancer over the past few years as well as our own research show that this treatment is safe and it is feasible to use 60Co as an alternative source.

The prognostic significance of pretreatment squamous cell carcinoma antigen levels in cervical cancer patients treated by concurrent chemoradiation therapy and a comparison of dosimetric outcomes and clinical toxicities between tomotherapy and volumetric modulated arc therapy

Background

To analyze the prognostic factors associated with stage IB-IVA cervical cancer in patients who underwent concurrent chemoradiation therapy (CCRT) and to compare the clinical toxicities and dosimetric parameters of organs at risk between the different radiotherapy techniques.

Methods

This retrospective study enrolled 93 patients with stage IB-IVA cervical cancer who underwent definitive CCRT between April 2009 and December 2017. Nine patients (9.7%) received 3DCRT, 43 patients (46.2%) underwent VMAT, and 41 patients (44.1%) received tomotherapy, and all of them followed by brachytherapy using a 2D planning technique. The treatment outcomes and related prognostic factors were analyzed. We also compared the clinical toxicities and dosimetric parameters between the different techniques used for the last 30 patients.

Results

With a median follow-up of 52.0 months, the 5-year overall survival (OS), progression-free survival (PFS), locoregional recurrence–free survival (LRRFS), and distant metastases–free survival (DMFS) were analyzed. In a Cox proportional hazards regression model, pretreatment SCC Ag > 10 ng/mL was a significant prognostic factor for PFS (hazard ratio [HR] 2.20; 95% confidence interval [CI] 1.03–4.70; P = 0.041), LRRFS (HR, 3.48; 95% CI 1.07–11.26; P = 0.038), and DMFS (HR 2.80; 95% CI 1.02–7.67; P = 0.045). Increasing the rectal volume receiving a radiation dose exceeding 30 Gy (V₃₀ of rectum; odds ratio [OR] 1.15; 95% CI 1.10–1.30; P = 0.03) was associated with a higher possibility of ≥ Grade 2 acute radiation therapy (RT)-related diarrhea. The median rectal V₃₀ values were 56.4%, 97.5%, and 86.5% for tomotherapy, 3-dimensional conformal radiation therapy (3DCRT), and volumetric modulated arc therapy (VMAT), respectively (P < 0.001). In addition, the chance of experiencing ≥ Grade 2 acute diarrhea were 10.0%, 66.7%, and 54.5% for tomotherapy, 3DCRT, and VMAT, respectively (P = 0.029).

Conclusions

Patients with pretreatment SCC Ag ≤ 10 ng/mL have better PFS, LRRFS, and DMFS than those with pretreatment SCC Ag > 10 ng/mL. The rectal V₃₀ is a significant predictor of severe acute diarrhea. Tomotherapy significantly decreased the rectal V₃₀, reducing the severity of acute RT-related diarrhea during external beam RT.

Trial registration This study was approved by the institutional review board at Kaohsiung Medical University Hospital. The registration number is KMUHIRB-E(I)-20190054 and retrospectively registered on 2019/3.

The Relationship Between Late Morbidity and Dose-Volume Parameter of Rectum in Combined Intracavitary/Interstitial Cervix Cancer Brachytherapy: A Mono-Institutional Experience

Purpose

To establish a dose volume–effect relationship for predicting late rectal complication (LRC) in locally advanced cervical cancer patients treated with external beam radiotherapy (EBRT) followed by combined intracavitary/interstitial brachytherapy (IC/IS-BT).

Materials and Methods

A retrospective analysis was performed in 110 patients with locally advanced cervical cancer who underwent definitive radiotherapy combined with IC/IS-BT from July 2010 to September 2018. We report the 90% of the target volume receiving the minimum dose for high risk clinical target volume (HR-CTV D₉₀) and intermediate risk clinical target volume (IR-CTV D₉₀), and the minimum doses to the most exposed 0.1, 1, and 2 cm³ D0.1cm3,D1cm3,D2cm3 doses at the International Commission on Radiation Units and Measurements (D_ICRU) for organs at risk (OARs). The total dose of EBRT plus brachytherapy was transformed to the biologically equivalent dose in 2 Gy fractions (EQD2) with α/β value of 10 Gy for target, 3 Gy for organs at risk using the linear quadratic model. The morbidity was scored according to the Radiation Therapy Oncology Group (RTOG) criteria. The Probit model was used to establish a prediction model on rectum between the organs at risk for dose and LRC. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of dose volume parameters for LRC.

Results

The median follow-up time was 72.3 months. The mean ( ± standard deviation) D2cm3,D1cm3,D0.1cm3, and D_ICRU values of rectum were 64.72 ± 7.47 Gy_EQD2, 70.18 ± 5.92 Gy_EQD2, 79.32 ± 7.86 Gy_EQD2, and 67.22 ± 7.87 Gy_EQD2, respectively. The Probit model showed significant relationships between D1cm3 or D0.1cm3, and the probability of grade1–4, grade 2–4 rectal events at 1 year, and between D1cm3and the probability of grade2–4 rectal events at 3 and 5 years. The dose values for 10% complication rates (ED10) of D1cm3were 74.18 (70.42–76.71) Gy_EQD2, 67.80 (59.91, 71.08) Gy_EQD2, 66.37 (52.00, 70.27) Gy_EQD2 for grade 2–4 with rectal morbidity at 1, 3, and 5 years, respectively.

Conclusion

Our study proved that D1cm3 andD0.1cm3were considered as useful dosimetric parameters for predicting the risk of grade1–4 and grade2–4 LRC at 1-year, and D1cm3might be an indicator for predicting grade2-4 LRC at 3/5years. The patients with rectal D1cm3>66.37–74.18 Gy_EQD2 should be closely observed for grade2–4 LRC.

The effect of dose-painted intensity-modulated radiotherapy combined with chemotherapy for stage IIIB cervical cancer

OBJECTIVE

To investigate the effect of dose-painted intensity-modulated radiotherapy (DP-IMRT) combined with chemotherapy on stage IIIB cervical cancer.

METHODS

A total of 107 stage IIIB cervical cancer patients were treated with DP-IMRT combined with chemotherapy. The planning target volume (PTV) was divided into regions with different prescribed absorbed doses (so-called PTV-subvolume [PTVsv]): PTVsv₁ (the part of the PTV that overlaps with the organ at risk (OAR)) received 39.6-45 Gy, 1.8 Gy/fraction (fx); and PTVsv₂ (the part of the PTV that does not overlap with the OAR) received 44-50 Gy, 2.0 Gy/fx. The lymph nodes were simultaneously boosted; lymph nodes with a short axis dimension <1 cm received 50-55 Gy, 2.0-2.4 Gy/fx, while nodes with a short axis dimension >1 cm received 55-66 Gy, 2.2-2.6 Gy/fx. External radiotherapy was followed by intracavitary brachytherapy. Patients were followed up regularly to collect the survival information.

RESULTS

Five years after therapy, the overall survival rate and progression-free survival rate were 61.0% and 55.0%, respectively. The cumulative rates for total grade 3 or higher chronic gastrointestinal or genitourinary toxicity were 4.67% and 1.9% respectively.

CONCLUSION

Without compromising the primary PTV, DP-IMRT achieved good outcomes for stage IIIB cervical cancer patients with a favorable gastrointestinal toxicity profile.

Intracavitary/Interstitial Applicator Plus Distal Parametrial Free Needle Interstitial Brachytherapy in Locally Advanced Cervical Cancer: A Dosimetric Study

Purpose

To explore the dosimetric advantage of combining intracavitary/interstitial applicator with distal parametrial free needle interstitial brachytherapy (IC/IS+ISBT DP) based on MRI for locally advanced cervical cancer.

Methods and Materials

77 IC/IS+ISBT DP treatment plans were developed for 34 patients with locally advanced cervical cancer from June 2016 to January 2020 in this study. We removed the free needles and devised a new IC/ISBT treatment plan based on the same principle. We then compared the dosimetric differences of D90, D98, V100, V150, V200 for HR-CTV (high-risk clinical target volume), D90 for IR-CTV (Intermediate risk-CTV) and D2cc for OARs (organs at risk) between the two groups of treatment plans for the same patient, and the paired T test was performed in parallel. Further, the dosage differences between the two group plans under different parametrial extension widths (the maximum distance of HR-CTV from the vertical direction of the uterine tandem at coronal position) were compared. The survival rate was calculated using the Kaplan-Meier method. Prognostic factors for overall survival (OS) and progression-free survival (PFS) were determined by Cox regression method. RTOG/EORTC criteria were used to grade toxicities.

Results

A total of 297 free needles were used, with a weight ratio of 15.8% ± 0.11, and a mean insertion depth of 6.52cm ± 2.8cm. D90, D98, V100 for HR-CTV, and D90 for IR-CTV for IC/IS+ISBT DP were significantly higher than IC/ISBT for which free needles were removed (p<0.05). And the V200 for HR-CTV and D2cc for bladder, rectum and sigmoid were decreased (p<0.05). When the parametrial extension widths were greater than 3cm, the HR-CTV D90 and the D2CC for rectum, bladder and sigmoid colon for IC/IS-ISBT DP were advantageous compared to IC/ISBT (p<0.05). The 2-yr OS, PFS and local control rate (LC) were 82.3, 66.8, and 93.1%, respectively. Parametrial extension widths was the only statistically prognostic factors for PFS (p = 0.002) on univariate analysis. No grade 3 or 4 Treatment-related toxicities were observed.

Conclusion

Our institutional experiences showed that IC/IS+ISBT DP is an effective treatment for cervical cancer patients with distal parametrial extension. IC/IS-ISBT DP had dosage advantage and clinical feasibility in locally advanced cervical cancer with distal parametrial extension when the parametrial extension widths were greater than 3cm.

A phase III randomised trial of trans-abdominal ultrasound in improving application quality and dosimetry of intra-cavitary brachytherapy in locally advanced cervical cancer

INTRODUCTION

Intra-cavitary brachytherapy (ICB) remains an integral part of radiotherapy treatment in cervical cancer. Two-dimensional X ray point-based planning remains common and blind insertion leads to uterine perforations and higher toxicity. We conducted a randomised controlled trial of using trans-abdominal ultrasound in performing ICB to reduce perforation and organ at risk doses.

PATIENT AND METHODS

The present study is a phase III open label randomised controlled trial of ultrasound guided ICB conducted on invasive cervical cancer patients. Patients were randomised by a simple computer-generated randomization chart into Arm A (No Ultrasound guidance) and Arm B (ICB with ultrasound guidance). The uterine perforation rates, tandem length change rates, bladder doses, rectal dose and procedure times were compared. Fischer exact test was used to compare the arms and p value <0.05 considered significant.

RESULTS

A total of 160 patients were randomised. With US assistance, the uterine perforation rate was 1.25% (n = 1). In the non-US assistance arm the perforation rate was 12.5% (n = 10) (p = 0.005). Mean time to complete the entire procedure was significantly shortened from 26 min to 19 min favouring the US arm (p = 0.001). Dosimetric assessment between the two groups showed significant decrease in dose received by the various organs at risk with US assistance.

CONCLUSION

The present study confirms significant improvement in application quality as well as dosimetry with reduction in procedure time. Trans-Abdominal US should be routinely used for ICB procedures, particularly in resource limited settings.

Three-dimensional image-guided combined intracavitary and interstitial high-dose-rate brachytherapy in cervical cancer: A systematic review

PURPOSE

To evaluate the local control and toxicities of three-dimensional image-guided combined intracavitary and interstitial (IC/IS) high-dose-rate brachytherapy (BT) in cervical cancer through a systematic review.

METHODS AND MATERIALS

A systematic review of relevant studies was performed through the PubMed, Web of Science, and Cochrane Library databases through May 10, 2020. Articles reporting on IC/IS technology, volumetric doses to high-risk clinical target volume (HR-CTV) and organs at risk (OARs), tumor control and/or treatment-related side effects were identified. The key information, including the type of applicator, implantation technology, characteristics of implantation, volumetric doses, tumor control, and/or treatment-related side effects, was extracted. A probit model analysis between HR-CTV D90 and tumor local control was performed.

RESULTS

Twelve studies encompassing 520 patients were included in the probit model between HR-CTV D90 and the local control rate. The probit model showed a significant relationship between the HR-CTV D90 value and the local control probability, p = 0.003. The prescribed dose of 85 Gy_EQD2,10 would in theory warrant an 87.4% (95% confidence interval 82.5%-90.5%) local control rate.

CONCLUSION

IC/IS BT is an appropriate method to achieve a high therapeutic ratio for tumors with large volumes or poor responses after external irradiation in cervical cancer. The probit model showed that the dose escalation of HR-CTV D90 was helpful to improve the local tumor control rate.

Tumor growth patterns on magnetic resonance imaging and treatment outcomes in patients with locally advanced cervical cancer treated with definitive radiotherapy

BACKGROUND

To evaluate the prognostic value of tumor growth patterns on magnetic resonance (MR) images in patients with locally advanced cervical cancer (LACC) treated with definitive radiotherapy or concurrent chemoradiotherapy (RT/CCRT).

METHODS

We retrospectively reviewed 102 patients with LACC who received definitive RT/CCRT and who underwent MR imaging before RT/CCRT. Growth patterns on pretreatment T2-weighted MR images were classified into expansive or infiltrative type according to tumor morphologic patterns in the myometrium and/or parametrial space.

RESULTS

The median age was 60 years (range 26-90 years). The median follow-up time was 47.7 months (range 5.7-123 months). The numbers of patients with stages IB, II, III, and IVA were 17, 39, 43, and 3, respectively. The 3-year overall survival (OS) rates for stages IB, II, III, and IV were 87%, 76%, 74%, and 67%, respectively. Regarding growth patterns on MR images, 31 were of expansive type and 71 were of infiltrative type. The infiltrative type was significantly associated with lower OS and locoregional recurrence-free survival (LRRFS) than the expansive type (3-year OS, 70% vs. 93%, p = 0.003; 3-year LRRFS, 64% vs. 94%, p = 0.001). On multivariate analysis, infiltrative tumor growth patterns were a significant independent factor for low OS (hazard ratio [HR], 3.81; 95% confidence interval [CI] 1.26-16.7; p = 0.015) and low LRRFS (HR, 4.27; 95% CI 1.43-18.5; p = 0.007).

CONCLUSION

Tumor growth patterns on MR images could be an indicator of survival and locoregional control in patients with LACC treated with definitive RT/CCRT.

Hyaluronic gel injection into the vesicovaginal septum for high-dose-rate brachytherapy of uterine cervical cancer: an effective approach for bladder dose reduction

Purpose

The purpose of this study was to report our initial experience of hyaluronic acid gel injection (HGI) in the vesicovaginal septum (VVS) for bladder dose reduction in brachytherapy (BT) for uterine cervical carcinoma.

Material and methods

Between September 2016 and May 2018, 15 uterine cervical cancer patients received HGI in the VVS as a part of their definitive radiotherapy (RT) treatment consisting of external beam radiation therapy (EBRT) with additional BT. Of those, 9 patients received BT both with and without HGI, and remaining 6 patients were excluded because these 6 patients received HGI in the VVS for all BT fractions. All 9 patients received HGI in the rectovaginal septum. For these patients, the dosimetric parameters bladder D_2cc, HR-CTV D₉₀, and rectum D_2cc were selected, and two groups were generated (BT with vs. without HGI in the VVS) for dosimetric comparison.

Results

The median cumulative EQD₂ for HR-CTV, rectum D_2cc, and bladder D_2cc for the 9 patients were 73.3, 52.8, and 67.1, respectively. While no statistical difference could be detected for rectal dose reduction, bladder dose was significantly less in the group with HGI in the VVS compared to that without (449 cGy [range, 416-566, 1SD = 66.1] vs. 569 cGy [range, 449-647, 1SD = 59.5], p = 0.033), with no compromising of target coverage. Although it did not reach statistically significance, there was a trend toward better HR-CTV D₉₀ in the group with HGI compared to that without HGI in the VVS (713 cGy vs. 706 cGy, p = 0.085). No severe bleeding, hematuria, bladder wall injury, or urethral injury requiring hospitalization was experienced in association with HGI in the VVS.

Conclusions

HGI in the VVS can be performed safely and can effectively reduce the bladder dose in BT for uterine cervical cancer patients.

Intensity-modulated radiation therapy for definitive treatment of cervical cancer: a meta-analysis

Background

To compare the efficacies and toxicities of intensity-modulated radiotherapy (IMRT) with three-dimensional conformal radiotherapy (3D-CRT) or conventional two-dimensional radiotherapy (2D-RT) for definitive treatment of cervical cancer.

Methods

A meta-analysis was performed using search engines, including PubMed, Cochrane Library, Web of Science, and Elsevier. In the meta-analysis, odds ratios (ORs) were compared for overall survival (OS), disease-free survival (DFS), and acute and chronic toxicities.

Results

Included data were analysed using RevMan 5.2 software. Six studies encompassing a total of 1008 patients who received definitive treatment (IMRT = 350, 3-DCRT/2D-RT = 658) were included in the analysis. A comparison of 3-year OS and 3-year DFS revealed no significant differences between IMRT and 3D-CRT or 2D-RT (3-year OS: OR = 2.41, 95% confidence interval [CI]: 0.62–9.39, p = 0.21; 3-year DFS: OR = 1.44, 95% CI: 0.69–3.01, p = 0.33). The incidence of acute gastrointestinal (GI) toxicity and genitourinary (GU) toxicity in patients who received IMRT was significantly lower than that in the control group (GI: Grade 2: OR = 0.5, 95% CI: 0.28–0.89, p = 0.02; Grade 3 or higher: OR = 0.55, 95% CI: 0.32–0.95, p = 0.03; GU: Grade 2: OR = 0.41, 95% CI: 0.2–0.84; p = 0.01; Grade 3 or higher: OR = 0.31, 95% CI: 0.14–0.67, p = 0.003). Moreover, the IMRT patients experienced fewer incidences of chronic GU toxicity than did the control group (Grade 3: OR = 0.09, 95% CI: 0.01–0.67, p = 0.02).

Conclusion

IMRT and conventional radiotherapy demonstrated equivalent efficacy in terms of 3-year OS and DFS. Additionally, IMRT significantly reduced acute GI and GU toxicities as well as chronic GU toxicity in patients with cervical cancer.