A Comparative Analysis of Two Different Dose Fractionation Regimens of High Dose Rate Intracavitary Brachytherapy in Treatment of Carcinoma of Uterine Cervix: A Prospective Randomized Study

Comparison of two high dose rate intracavitary brachytherapy regimens in treatment of cervical cancer: a preliminary report

BACKGROUND

To assess and compare the local control and toxicities between HDR Intracavitary Brachytherapy with 7.5 Gy and 9 Gy per fraction after EBRT in treatment of carcinoma cervix.

METHODOLOGY

A total of 180 patients were randomly assigned to 2 arms. Arm A received HDR intracavitary brachytherapy with a dose of 7.5 Gy per fraction, 1 fraction per week for 3 fractions and Arm B received 9 Gy per fraction, 1 fraction per week for 2 fractions. Patients were evaluated on follow up for assessment of local control and toxicities.

RESULTS

The median follow up was 12 months (6-18 months). In arm A 89% of the patient had complete response and 11% had recurrence or metastasis. In arm B 93% of the patient had complete response and 7% had recurrence or metastasis. Grade 2/3 diarrhoea was seen in 4.4% of patients in Arm A and in 7.7% in Arm B. Grade 2/3 proctitis was seen in 3.3% of patients in 7.5 Gy arm and in 6.6% in 9 Gy arm. One patient in each arm had grade 1 haematuria. The overall duration of treatment was significant lower in Arm B compared to Arm A (59 days vs 68 days, p = 0.01).

CONCLUSION

The result of this clinical study shows that Intracavitary brachytherapy with a dose of 9 Gy per fraction is non inferior to other schedules in term of local control and does not result in increased toxicity.

MRI-Directed Brachytherapy for Cancer of the Uterine Cervix: A Case Report, Review, and Perspective on the Importance of Widespread Use of This Technological Advance in the United States

Cervical cancer remains a major health challenge in the United States (US), especially among the low socioeconomic and African American populations. The demographics of Mississippi constitute a relatively high percentage of this high-risk population. External beam radiation therapy (EBRT) combined with concurrent chemotherapy and followed by brachytherapy is the gold standard of treatment for stage IB3 through IVA cervical cancer. Arguably, brachytherapy is the most important component of this treatment process. Patterns of Care studies (PCS) and other more recent studies have shown that brachytherapy cannot be omitted or replaced by conventional or image-guided EBRT. The last decade has witnessed the expanding use of image-guided brachytherapy (IGBT). Studies have established the superiority of IGBT over point-based brachytherapy. MRI is associated with superior soft tissue definition compared with CT and is emerging as the new standard of care. The Gynaecological Groupe Européen de Curiethérapie and the European Society for Radiotherapy and Oncology [(GYN) GEC-ESTRO] have recommended that the dose be prescribed to the high-risk clinical target volume (HR-CTV). This volume includes residual tumor present at the time of brachytherapy, the cervix, and any gray areas seen on the scan. The (GYN) GEC-ESTRO has shown that a dose of >8500 cGy delivered in <50 days results in an approximate 10% increase in pelvic control (PC), disease-specific survival, and overall survival (OS) compared to historical controls. The normal tissue toxicity is comparable or better than historical controls as well. This dose, while maintaining normal tissue constraints, may only be achievable with a hybrid intracavitary/interstitial (IC/IS) needle device guided by MRI-based targeting. 

The University of Mississippi Medical Center (UMMC) has initiated an MRI-based cervical brachytherapy program and has treated 18 patients to date; our experience confirms the above findings. In this report, we propose that MRI guidance is necessary and a hybrid IC/IS needle device is required to achieve adequate dose coverages.

Management of cervical cancer during the corona virus disease-19 (COVID-19) era

COVID-19 pandemic has had a catastrophic impact on the society, economy and heath-care system all over the globe with virus showing no signs of losing potency. As the situation appears to worsen, extra burden on other specialities like oncology seems to increase. Specific recommendations are necessary for management of cervical cancer in the current context. All concerned specialities must work together in the best interest of the patient. Attempts should be made at managing cervical cancer while limiting the viral spread among the patients and health-care workers without the loss of opportunity. Surgical intervention for early cervical cancer should be postponed or alternative modalities be considered. In a locally advanced disease, concurrent chemoradiation is the treatment of choice. In addition, the following under mentioned suggestions aim to discuss ways of minimizing infection spread, workload rationalization and providing guidance for management of cervical cancer in the presence of COVID-19 infection.

COVID-19 impact on timing of brachytherapy treatment and strategies for risk mitigation

PURPOSE

The purpose of this study was to highlight the importance of timely brachytherapy treatment for patients with gynecologic, breast, and prostate malignancies, and provide a framework for brachytherapy clinical practice and management in response to the COVID-19 pandemic.

METHODS AND MATERIALS

We review amassing evidence to help guide the management and timing of brachytherapy for gynecologic, breast, and prostate cancers. Where concrete data could not be found, peer-reviewed expert opinion is provided.

RESULTS

There may be a significant negative impact on oncologic outcomes for patients with gynecologic malignancies who have a delay in the timely completion of therapy. Delay of prostate or breast cancer treatment may also impact oncologic outcomes. If a treatment delay is expected, endocrine therapy may be an appropriate temporizing measure before delivery of radiation therapy. The use of shorter brachytherapy fractionation schedules will help minimize patient exposure and conserve resources.

CONCLUSIONS

Brachytherapy remains a critical treatment for patients and may shorten treatment time and exposure for some. Reduced patient exposure and resource utilization is important during COVID-19. Every effort should be made to ensure timely brachytherapy delivery for patients with gynecologic malignancies, and endocrine therapy may help temporize treatment delays for breast and prostate cancer patients. Physicians should continue to follow developing institutional, state, and federal guidelines/recommendations as challenges in delivering care during COVID-19 will continue to evolve.

Brachytherapy in cervical cancer radiotherapy during COVID-19 pandemic crisis: problems and prospects

COVID-19 pandemic has adversely affected general healthcare delivery systems and cancer care throughout the world. The management of locally advanced cervical cancer presents specific challenges in this context, especially brachytherapy and completion of radiotherapy treatment, without compromising the overall treatment time and anticipated outcomes. This article presents in detail the issues and possible solutions with currently available literature for COVID-19 and radiation, in particular brachytherapy management of locally advanced cervical cancers. The review attempts to provide possible explanations and pathways based on COVID-19 testing, brachytherapy processes including application, imaging, and fractionation, keeping in mind the overall treatment time.

Comparison of iso-effective and cost-effective high-dose-rate brachytherapy treatment schedules in cervical cancer - regional cancer center experience

Purpose

The study is to evaluate the difference between outcomes of two high-dose-rate fractionation schedules in the treatment of intracavitary brachytherapy (ICBT) of cervical cancer.

Material and methods

A retrospective analysis of 163 cervical cancer patients was completed. All patients received external beam radiotherapy (EBRT) to whole pelvis with concurrent weekly chemotherapy, followed by ICBT with either 7 Gy per fraction in three fractions (arm A) or 9 Gy per fraction in two fractions (arm B). Median follow-up was 19 months. The outcomes were compared in terms of 2-year actuarial local control, disease-free survival, overall survival, and late toxicity in the two treatment arms.

Results

The 2-year actuarial local control rates in arm A and arm B were 88.5% and 91.5%, respectively. The actuarial 2-year disease-free survival rates in arm A and arm B were 85.9% and 82.6%, respectively. The actuarial 2-year overall survival in arm A and arm B were 95.7% and 100%, respectively (p = 0.06). There were 12.7% and 15.2% local failures in arm A and arm B, respectively. Distant metastases were seen in 8.5% and 7.6% in arm A and arm B, respectively. The 2-year actuarial risk of developing late rectal toxicity in arm A and arm B were 5.6% and 5.4%, respectively. The 2-year actuarial risk of developing late bladder toxicity in arm A and arm B were 2.8% and 2.2%, respectively.

Conclusions

ICBT treatment with 9 Gy in two fractions offers equivocal local control rates and survival rates in cancer cervix cases with many advantages of short overall treatment time, improved patient compliance, cost effectiveness, and reduced exposure to aesthetic agents. The toxicities observed were few, low grade, and easily manageable.

Impact of different dose prescription schedules on EQD2 in high-dose-rate intracavitary brachytherapy of carcinoma cervix

Purpose

To observe the effect of different high-dose-rate (HDR) intracavitary brachytherapy dose schedules on equieffective dose in 2 Gy per fraction (EQD₂).

Material and methods

It is a retrospective study involving 50 cervical cancer patients, who received external radiotherapy of 45 Gy in 25 fractions and underwent intracavitary brachytherapy (ICBT). Computed tomography (CT) simulation was done after insertion of the applicators. High-risk clinical target volume (CTVHR) and organs at risk (OARs) such as bladder, rectum, and sigmoid were contoured. Four different plans were generated for each patient, with dose prescriptions of 5.5 Gy × 5 fractions (plan A), 6.5 Gy × 4 fractions (plan B), 7 Gy × 4 fractions (plan C), and 9 Gy × 2 fractions (plan D), delivered to CTV_HR. The total EQD₂ for 0.1 cm³ and 2 cm³ of bladder, rectum, and sigmoid as well as dose received by 90% of the CTV_HR (D₉₀) and point A were calculated. The values were analyzed and compared with available literature.

Results

The mean CTV_HR volume was 47.12 ±13.8 cm³. All plans delivered similar EQD₂ for 0.1 cm³ and 2 cm³ of sigmoid. Plan D delivered lesser EQD₂ compared to other plans for bladder, rectum, D₉₀ CTVHR, and point A (p = 0.0001). Plan C delivered higher EQD₂ to OARs compared to other plans (p = 0.001). Plan A, B, and plan C delivered similar EQD₂ for D₉₀ CTV_HR and point A.

Conclusions

EQD₂ of bladder, rectum, sigmoid, D₉₀ CTV_HR, and point A were similar with 5.5 Gy × 5 fractions, 6.5 Gy × 4 fractions, and 7 Gy × 4 fractions, whereas EQD₂ of 9 Gy × 2 fractions was significantly unfavorable compared to other schedules. Further clinical studies are recommended to observe clinical outcomes.