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Fotopoulou C, Eriksson AG, Planchamp F, Morice P, Taylor A, Sturdza A, Florin Coza O, Halaska MJ, Martinelli F, Armbrust R, Chargari C. European Society of Gynaecological Oncology expanded quality indicators and accreditation for cervical cancer management. Int J Gynecol Cancer 2024; 34:480-489. [PMID: 38395448 DOI: 10.1136/ijgc-2024-005293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Affiliation(s)
| | - Ane Gerda Eriksson
- Department of Gynecologic Oncology, Norwegian Radium Hospital, Oslo, Norway
- The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | | | - Philippe Morice
- Surgery, Gustave Roussy, Villejuif, Île-de-France, France
- Paris-South University/Paris Saclay, Paris, Île-de-France, France
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Ovidiu Florin Coza
- Iuliu Hagieganu University of Medicine and Pharmacy Faculty of Medicine, Cluj Napoca, Romania
- Oncology Institute "Prof. Dr.I.Chiricuta", Cluj Napoca, Romania
| | - Michael J Halaska
- Dept. of Obstetrics and Gynaecology, 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | | | - Robert Armbrust
- Dept. of Gynecology, Charite University Hospital Berlin, Berlin, Germany
| | - Cyrus Chargari
- Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
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Knoth J, Sturdza A, Zaharie A, Dick V, Kronreif G, Nesvacil N, Widder J, Kirisits C, Schmid MP. Transrectal ultrasound for intraoperative interstitial needle guidance in cervical cancer brachytherapy. Strahlenther Onkol 2024:10.1007/s00066-024-02207-9. [PMID: 38409394 DOI: 10.1007/s00066-024-02207-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE This study aimed to prospectively assess the visibility of interstitial needles on transrectal ultrasound (TRUS) in cervical cancer brachytherapy patients and evaluate its impact on implant and treatment plan quality. MATERIAL AND METHODS TRUS was utilized during and after applicator insertion, with each needle's visibility documented through axial images at the high-risk clinical target volume's largest diameter. Needle visibility on TRUS was scored from 0 (no visibility) to 3 (excellent discrimination, margins distinct). Quantitative assessment involved measuring the distance between tandem and each needle on TRUS and comparing it to respective magnetic resonance imaging (MRI) measurements. Expected treatment plan quality based on TRUS images was rated from 1 (meeting all planning objectives) to 4 (violation of High-risk clinical target volume (CTVHR) and/or organ at risk (OAR) hard constraints) and compared to the final MRI-based plan. RESULTS Analysis included 23 patients with local FIGO stage IB2-IVA, comprising 41 applications with a total of 230 needles. A high visibility rate of 99.1% (228/230 needles) was observed, with a mean visibility score of 2.5 ± 0.7 for visible needles. The maximum and mean difference between MRI and TRUS measurements were 8 mm and -0.1 ± 1.6 mm, respectively, with > 3 mm discrepancies in 3.5% of needles. Expected treatment plan quality after TRUS assessment exactly aligned with the final MRI plan in 28 out of 41 applications with only minor deviations in all other cases. CONCLUSION Real-time TRUS-guided interstitial needle placement yielded high-quality implants, thanks to excellent needle visibility during insertion. This supports the potential of TRUS-guided brachytherapy as a promising modality for gynecological indications.
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Affiliation(s)
- J Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - A Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - A Zaharie
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - V Dick
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - G Kronreif
- Austrian Center for Medical Innovation and Technology, Wiener Neustadt, Austria
| | - N Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - J Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - C Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - M P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Ecker S, Kirisits C, Schmid M, Knoth J, Heilemann G, De Leeuw A, Sturdza A, Kirchheiner K, Jensen N, Nout R, Jürgenliemk-Schulz I, Pötter R, Spampinato S, Tanderup K, Eder-Nesvacil N. EviGUIDE - a tool for evidence-based decision making in image-guided adaptive brachytherapy for cervical cancer. Radiother Oncol 2023; 186:109748. [PMID: 37330055 DOI: 10.1016/j.radonc.2023.109748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE To develop a novel decision-support system for radiation oncology that incorporates clinical, treatment and outcome data, as well as outcome models from a large clinical trial on magnetic resonance image-guided adaptive brachytherapy (MR-IGABT) for locally advanced cervical cancer (LACC). METHODS A system, called EviGUIDE, was developed that combines dosimetric information from the treatment planning system, patient and treatment characteristics, and established tumor control probability (TCP), and normal tissue complication probability (NTCP) models, to predict clinical outcome of radiotherapy treatment of LACC. Six Cox Proportional Hazards models based on data from 1341 patients of the EMBRACE-I study have been integrated. One TCP model for local tumor control, and five NTCP models for OAR morbidities. RESULTS EviGUIDE incorporates TCP-NTCP graphs to help users visualize the clinical impact of different treatment plans and provides feedback on achievable doses based on a large reference population. It enables holistic assessment of the interplay between multiple clinical endpoints and tumour and treatment variables. Retrospective analysis of 45 patients treated with MR-IGABT showed that there exists a sub-cohort of patients (20%) with increased risk factors, that could greatly benefit from the quantitative and visual feedback. CONCLUSION A novel digital concept was developed that can enhance clinical decision- making and facilitate personalized treatment. It serves as a proof of concept for a new generation of decision support systems in radiation oncology, which incorporate outcome models and high-quality reference data, and aids the dissemination of evidence-based knowledge about optimal treatment and serve as a blueprint for other sites in radiation oncology.
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Affiliation(s)
- Stefan Ecker
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria.
| | - Christian Kirisits
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Maximilian Schmid
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Johannes Knoth
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Gerd Heilemann
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Astrid De Leeuw
- University Medical Centre Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Alina Sturdza
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Kathrin Kirchheiner
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Nina Jensen
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Remi Nout
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Ina Jürgenliemk-Schulz
- University Medical Centre Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Richard Pötter
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Sofia Spampinato
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
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Knoth J, Konrad S, Lössl K, Motisi L, Mäurer M, Linde P, Lindel K, Niehoff P, Strnad V, Sturdza A, Corradini S. Survey on brachytherapy training among radiation oncology residents in the German-speaking regions of Europe. Strahlenther Onkol 2023; 199:798-805. [PMID: 37462693 PMCID: PMC10450005 DOI: 10.1007/s00066-023-02108-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/04/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE This survey aimed to determine the perception of brachytherapy training among residents in the DACH region, consisting of Austria, Germany and Switzerland. MATERIAL & METHODS An online questionnaire containing 22 questions related to trainee demographics (n = 5) and to brachytherapy training (n = 17) was sent in two iterations in 11/2019 and 02/2020. The following topics were evaluated: institutional support, barriers to training, extent of training, site-specific training (prostate, gynaecology, breast, gastrointestinal and skin), preferences for further training and outlook on overall development of brachytherapy. The responses were mostly based on a Likert scale of 1 to 5, thereby reflecting strength of opinion. Descriptive statistics were used to describe frequencies. RESULTS Among the 108 respondents, approximately 69% of residents considered the ability to perform brachytherapy independently to be important or somewhat important. However, only 31% of respondents reported to have a dedicated brachytherapy training during residency. The major limitation to achieve independence in performing brachytherapy was seen in a low case load in Austria, in the lack of training in Switzerland and in both of them in Germany. CONCLUSION The interest in brachytherapy training among residents in German-speaking countries was generally high, but there is a perceived lack of sufficient case volumes and partially also in formal training opportunities. Fellowships at departments with a high case load as part of a formalised curriculum and dedicated hands-on workshops at national or international conferences might help to overcome these issues.
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Affiliation(s)
- Johannes Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürel 8-20, 1090, Vienna, Austria.
| | - Stefan Konrad
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürel 8-20, 1090, Vienna, Austria
| | - Kristina Lössl
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laura Motisi
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Mäurer
- Department for Radiotherapy and Radiation Oncology, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
- Clinician Scientist Program "OrganAge", Jena University Hospital, 07747, Jena, Germany
| | - Philipp Linde
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937, Cologne, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Klinikum Karlsruhe, Karlsruhe, Germany
| | | | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürel 8-20, 1090, Vienna, Austria
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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Oonk MHM, Planchamp F, Baldwin P, Mahner S, Mirza MR, Fischerová D, Creutzberg CL, Guillot E, Garganese G, Lax S, Redondo A, Sturdza A, Taylor A, Ulrikh E, Vandecaveye V, van der Zee A, Wölber L, Zach D, Zannoni GF, Zapardiel I. European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023. Int J Gynecol Cancer 2023; 33:1023-1043. [PMID: 37369376 PMCID: PMC10359596 DOI: 10.1136/ijgc-2023-004486] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/20/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer. OBJECTIVE To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer. METHODS The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives. RESULTS The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.
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Affiliation(s)
- Maaike H M Oonk
- University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Sven Mahner
- University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | | | - Daniela Fischerová
- Charles University First Faculty of Medicine, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | | | | | - Giorgia Garganese
- Catholic University of the Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sigurd Lax
- Hospital Graz II, Graz, Austria
- Johannes Kepler Universitat Linz, Linz, Austria
| | | | | | | | - Elena Ulrikh
- Almazov National Medical Research Center, Saint Petersburg, Russian Federation
| | | | - Ate van der Zee
- University Medical Center Groningen, Groningen, The Netherlands
| | - Linn Wölber
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diana Zach
- Karolinska University Hospital, Stockholm, Sweden
- Karolinska Institutet Eugeniavägen, Stockholm, Sweden
| | - Gian Franco Zannoni
- Catholic University of the Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Chargari C, Tanderup K, Planchamp F, Chiva L, Humphrey P, Sturdza A, Tan LT, van der Steen-Banasik E, Zapardiel I, Nout RA, Fotopoulou C. ESGO/ESTRO quality indicators for radiation therapy of cervical cancer. Radiother Oncol 2023; 183:109589. [PMID: 37268359 DOI: 10.1016/j.radonc.2023.109589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer. OBJECTIVE To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. METHODS Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n = 99). RESULTS Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes. DISCUSSION This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.
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Affiliation(s)
| | | | | | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Pauline Humphrey
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Wien, Austria
| | - Li T Tan
- Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, the Netherlands
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7
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Chargari C, Tanderup K, Planchamp F, Chiva L, Humphrey P, Sturdza A, Tan LT, van der Steen-Banasik E, Zapardiel I, Nout RA, Fotopoulou C. ESGO/ESTRO quality indicators for radiation therapy of cervical cancer. Int J Gynecol Cancer 2023:ijgc-2022-004180. [PMID: 37258414 DOI: 10.1136/ijgc-2022-004180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer. OBJECTIVE To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. METHODS Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n=99). RESULTS Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes. DISCUSSION This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.
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Affiliation(s)
| | | | | | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Pauline Humphrey
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Wien, Austria
| | - Li T Tan
- Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, Netherlands
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Bindal A, Mittal P, Shinghal A, Scaria L, Prajapati K, Swamidas J, Gurram L, Berger D, Sturdza A, Chopra S. Sigmoid dose accumulation and reporting for multifractionated brachytherapy for cervical cancer: Methodological development of sigmoid points through virtual endoscopic method. Brachytherapy 2023; 22:325-333. [PMID: 36882345 DOI: 10.1016/j.brachy.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/09/2022] [Accepted: 01/13/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The sigmoid is an important organ at risk for gynecological brachytherapy (BT). However, the reliability of localization of high-dose regions during multi-fractionated treatment is limited. This work reports the methodological development of sigmoid points to summate multi-fractionated doses. METHODS AND MATERIAL Ten paired MRI data sets of ring-based intracavitary brachytherapy were obtained. Simulating a virtual endoscope, a reference line was created along the central axis of the anorectosigmoid for each implant. A trendline was generated, and linear dose was determined. Three-dimensional (3D) coordinates of high-dose regions were identified, and overlap was determined. In the next step, 3D coordinates of high-dose sigmoid points were localized in reference to cervical os and re-verified for location in reference to sigmoid lumen and corroboration with 2cc doses. With minor modifications, sigmoid points were proposed. RESULTS In 6 of 10 patients, high-dose regions co-localized in subsequent fractions of BT. Three high-dose regions were identified along the sigmoid length and proposed as sigmoid points in reference to cervical os. (S1'= 0.5 cm right, 1.5 cm posterior, and 2.4 cm cranial; S2' = 0.3 cm anterior and 4.5 cm cranial; S3' = 2.7 cm left, 3 cm anterior, and 3.6 cm cranial to the cervical os). S1' and S2' were located in the sigmoid in 70% and 60% of data sets. The mean difference between D2cc and S1'/S2' was 0.30 Gy and 1.06 Gy respectively. S3' had limited corroboration to sigmoid lumen or 2 cc doses. The points S1' and S2' were further modified (minor) for applicability and proposed as sigmoid points 1 and 2 (SP1 0.5 right,1.5 posterior and 2.5 cm cranial to cervical os and SP2 (0.5 cm anterior and 4.5 cm cranial to cervical os)). CONCLUSION SP1 and SP 2 are proposed as a surrogate for 2 cc sigmoid doses and may provide a method of reliable inter-fraction dose summation. This pilot work requires further validation.
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Affiliation(s)
- Arpita Bindal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prachi Mittal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Abhishek Shinghal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Libin Scaria
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kunal Prajapati
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jamema Swamidas
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Lavanya Gurram
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Daniel Berger
- Department of Radiation Oncology and Medical Physics, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology and Medical Physics, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
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9
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Dizendorf E, Sturdza A, Tagliaferri L, Russo L, Nesvacil N, Kirisits C. Implementation of online workshops on image-guided adaptive brachytherapy (interventional radiotherapy) in locally advanced cervical cancer: Experience of BrachyAcademy. Brachytherapy 2023; 22:343-351. [PMID: 36828765 DOI: 10.1016/j.brachy.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE To provide educational support to brachytherapy users during the COVID-19 pandemic, online workshops were developed and implemented by BrachyAcademy, non-profit peer-to-peer educational initiative in Elekta. METHODS AND MATERIALS In 2021-2022 two online workshops were organized. Participating teams had to send a clinical case of locally advanced cervical cancer (LACC) including brachytherapy Digital Imaging and Communications in Medicine (DICOM) files and questions to the faculty. During the workshop, feedback was given to each clinical case by five faculty members (two Radiation Oncologists, one Radiologist, two Medical Physicists). Participants competed a post-workshop questionnaire which included combination of qualitative and quantitative questions via yes/no responses, Likert scale, and 1 to 10 scale. RESULTS Twenty-one teams from eight countries (Europe, Asia, Latin America) participated in two online workshops. The total number of participants was 49. The clinical cases represented LACC with The International Federation of Gynecology and Obstetrics (FIGO) stages from IB3 to IVA. During both, Workshop1 (W1) and Workshop 2 (W2) the following areas of improvement were identified: familiarity with the GEC ESTRO and The International Commission on Radiation Units & Measurements, Report 89 (ICRU 89) recommendations for contouring and planning based on clinical drawings and MRI sequencing choice; appropriate applicator selection; experience with interstitial needles; appropriate applicator reconstruction; dose optimization. The participants rated both workshops with overall scores 8,3 for W1, and 8,5 for W2. In 82% participants the training course fully met expectations for W1, and in 76% in W2. CONCLUSIONS We successfully implemented the online workshops on image-guided adaptive brachytherapy (IGABT) in LACC. Main performance issues and areas for improvement were identified based on multidisciplinary discussion of participant's clinical cases through all steps of the brachytherapy procedure. We encourage teams to consider online workshops in addition to hands-on training.
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Affiliation(s)
- Elena Dizendorf
- Nucletron Operations B.V. (Elekta), Veenendaal, The Netherlands
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Russo
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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10
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Spampinato S, Tanderup K, Lindegaard JC, Schmid MP, Sturdza A, Segedin B, Jürgenliemk-Schulz IM, De Leeuw A, Bruheim K, Mahantshetty U, Chargari C, Rai B, Cooper R, van der Steen-Banasik E, Sundset M, Wiebe E, Villafranca E, Van Limbergen E, Pieters BR, Tee Tan L, Lutgens LCHW, Hoskin P, Smet S, Pötter R, Nout R, Chopra S, Kirchheiner K. Association of persistent morbidity after radiotherapy with quality of life in locally advanced cervical cancer survivors. Radiother Oncol 2023; 181:109501. [PMID: 36720348 DOI: 10.1016/j.radonc.2023.109501] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE To quantify the association of persistent morbidity with different aspects of quality of life (QOL) in locally advanced cervical cancer (LACC) survivors. MATERIAL AND METHODS Longitudinal outcome from the EMBRACE-I study was evaluated. Patient-reported symptoms and QOL were prospectively scored (EORTC-C30/CX24) at baseline and regular follow-ups. Physician-assessed symptoms were also reported (CTCAEv.3). Persistent symptoms were defined if present in at least half of the follow-ups. QOL items were linearly transformed into a continuous scale. Linear mixed-effects models (LMM) were applied to evaluate and quantify the association of persistent symptoms with QOL. Overall QOL deterioration was evaluated by calculating the integral difference in QOL over time obtained with LMM for patients without and with persistent symptoms. RESULTS Out of 1416 patients enrolled, 741 with baseline and ≥ 3 late follow-ups were analyzed (median 59 months). Proportions of persistent EORTC symptoms ranged from 21.8 % to 64.9 % (bowel control and tiredness). For CTCAE the range was 11.3-28.6 % (limb edema and fatigue). Presence of any persistent symptom was associated with QOL, although with varying magnitude. Role functioning and Global health/QOL were the most impaired aspects. Fatigue and pain showed large differences, with reductions of around 20 % for most of the QOL aspects. Among organ-related symptoms, abdominal cramps showed the largest effect. CONCLUSION Persistent symptoms are associated with QOL reductions in LACC survivors. Organ-related symptoms showed smaller differences than general symptoms such as fatigue and pain. In addition to optimizing treatment to minimize organ-related morbidity, effort should be directed towards a more comprehensive and targeted morbidity management.
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Affiliation(s)
- Sofia Spampinato
- Danish Center for Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark.
| | - Kari Tanderup
- Danish Center for Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark.
| | - Jacob C Lindegaard
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark.
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, 1000 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia.
| | - Ina M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands.
| | - Astrid De Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands.
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, 0450 Oslo, Norway.
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai and Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh 530053, India.
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, 94805 Villejuif, France.
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds LS9 7LP, United Kingdom.
| | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, 7030 Trondheim, Norway.
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton AB T6G 1Z2, Canada.
| | - Elena Villafranca
- Department of Radiation Oncology, Hospital of Navarra, 31008 Pamplona, Navarra, Spain.
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, 3000 Leuven, Belgium.
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1081 HV Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, 1081 HV Amsterdam, the Netherlands.
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom.
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, 6229 ET Maastricht, the Netherlands.
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood HA6 2RN, United Kingdom.
| | - Stéphanie Smet
- Department of Radiation Oncology, Algemeen Ziekenhuis Turnhout, 2300 Turnhout, Belgium.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Remi Nout
- Department of Clinical Oncology, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai 410210, India.
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
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11
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Schmid MP, Lindegaard JC, Mahantshetty U, Tanderup K, Jürgenliemk-Schulz I, Haie-Meder C, Fokdal LU, Sturdza A, Hoskin P, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, van der Steen-Banasik E, Van Limbergen E, Pieters BR, Petric P, Ramazanova D, Ristl R, Kannan S, Hawaldar R, Ecker S, Kirchheiner K, Tan LT, Nout R, Nesvacil N, de Leeuw A, Pötter R, Kirisits C. Risk Factors for Local Failure Following Chemoradiation and Magnetic Resonance Image-Guided Brachytherapy in Locally Advanced Cervical Cancer: Results From the EMBRACE-I Study. J Clin Oncol 2023; 41:1933-1942. [PMID: 36599120 DOI: 10.1200/jco.22.01096] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To report clinical and treatment characteristics, remission and failure patterns, and risk factors for local failure (LF) from the EMBRACE-I study. MATERIALS AND METHODS EMBRACE-I was a prospective, observational, multicenter cohort study on magnetic resonance imaging-based image-guided adaptive brachytherapy (MR-IGABT) in locally advanced cervical cancer. Treatment consisted of external beam radiotherapy, concurrent chemotherapy, and MR-IGABT. LF was defined as progressive or recurrent disease in the cervix, uterus, parametria, pelvic wall, or vagina. Competing risk analysis was used to estimate local tumor control (LC) and Cox proportional regression models for multivariable analysis and dose-response analysis. RESULTS One thousand three hundred eighteen patients with a median follow-up of 52 months were available for this analysis. Eighty-one patients had persistent disease 3 months after end of treatment. Of those, 60 patients achieved LC at 6-9 months without further treatment, whereas 21 patients had progressive disease. In addition, 77 patients developed a local recurrence after complete remission comprising a total number of 98 LFs. LFs were located inside the MR-IGABT target volumes in 90% of patients with LF. In multivariable analysis, histology, minimal dose to 90% of high-risk clinical target volume (CTVHR), maximum tumor dimension, CTVHR > 45 cm3, overall treatment time, tumor necrosis on magnetic resonance imaging at diagnosis, uterine corpus infiltration at diagnosis and at MR-IGABT, and mesorectal infiltration at MR-IGABT had significant impact on LF. Dose-response analysis showed that a minimal dose to 90% of 85 Gy to the CTVHR led to 95% (95% CI, 94 to 97) LC 3 years postintervention for squamous cell in comparison to 86% (95% CI, 81 to 90) for adeno/adenosquamous carcinoma histology. CONCLUSION The present study demonstrates the safety and validity of the GYN GEC-ESTRO/ICRU-89 target concept and provides large-scale evidence for dose prescription and new risk factors for LF in MR-IGABT in locally advanced cervical cancer.
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Affiliation(s)
- Maximilian P Schmid
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
| | | | - Umesh Mahantshetty
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai and Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam, India
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Ina Jürgenliemk-Schulz
- University Medical Centre Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | | | - Lars U Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Alina Sturdza
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Barbara Segedin
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- The Norwegian Radium Hospital, Oslo University Hospital, Department of Oncology, Oslo, Norway
| | - Fleur Huang
- Cross Cancer Institute and University of Alberta, Department of Oncology, Edmonton, Canada
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Department of Radiotherapy and Oncology, Chandigarh, India
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley R Pieters
- Amsterdam University Medical Centers, University of Amsterdam, Department of Radiation Oncology, Amsterdam, the Netherlands
| | - Primoz Petric
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Dariga Ramazanova
- Medical University of Vienna, Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria
| | - Robin Ristl
- Medical University of Vienna, Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria
| | - Sadhana Kannan
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai and Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam, India
| | - Rohini Hawaldar
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai and Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam, India
| | - Stefan Ecker
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
| | - Kathrin Kirchheiner
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
| | - Li Tee Tan
- Cambridge University Hospitals, Department of Oncology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Remi Nout
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Nicole Nesvacil
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
| | - Astrid de Leeuw
- University Medical Centre Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Richard Pötter
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
| | - Christian Kirisits
- Medical University of Vienna, Department of Radiation Oncology- Comprehensive Cancer Center, Vienna, Austria
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12
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Sturdza A. SP-0196 Status of brachytherapy education for brachytherapists and future needs in Europe. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)03911-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Spampinato S, Tanderup K, Nout R, Smet S, Lindegaard J, Fokdal L, Pötter R, Sturdza A, Segedin B, Jürgenliemk-Schulz I, Bruheim K, Mahantshetty U, Chargari C, Rai B, Cooper R, van der Steen-Banasik E, Sundset M, Wiebe E, Villafranca E, Van Limbergen E, Chopra S, Kirchheiner K. OC-0588 Impact of persistent symptoms on long-term quality of life of cervical cancer survivors in EMBRACE I. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02610-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Beckmann MW, Stübs FA, Koch MC, Mallmann P, Dannecker C, Dietl A, Sevnina A, Mergel F, Lotz L, Hack CC, Ehret A, Gantert D, Martignoni F, Cieslik JP, Menke J, Ortmann O, Stromberger C, Oechsle K, Hornemann B, Mumm F, Grimm C, Sturdza A, Wight E, Loessl K, Golatta M, Hagen V, Dauelsberg T, Diel I, Münstedt K, Merz E, Vordermark D, Lindel K, Wittekind C, Küppers V, Lellé R, Neis K, Griesser H, Pöschel B, Steiner M, Freitag U, Gilster T, Schmittel A, Friedrich M, Haase H, Gebhardt M, Kiesel L, Reinhardt M, Kreißl M, Kloke M, Horn LC, Wiedemann R, Marnitz S, Letsch A, Zraik I, Mangold B, Möckel J, Alt C, Wimberger P, Hillemanns P, Paradies K, Mustea A, Denschlag D, Henscher U, Tholen R, Wesselmann S, Fehm T. Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) – Part 1 with Recommendations
on Epidemiology, Screening, Diagnostics and Therapy. Geburtshilfe Frauenheilkd 2022; 82:139-180. [DOI: 10.1055/a-1671-2158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022] Open
Abstract
Abstract
Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This
updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of
Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische
Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG).
Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of
existing evidence-based national and international guidelines or – if evidence was lacking – on a consensus of the specialists involved in compiling the update. After an initial review of
the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new
recommendations or statements which took account of more recently published literature and the appraisal of the new evidence.
Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical
cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up
to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated
radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.
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Affiliation(s)
- Matthias W. Beckmann
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Frederik A. Stübs
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Martin C. Koch
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | | | | | - Anna Dietl
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Anna Sevnina
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Franziska Mergel
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Laura Lotz
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Carolin C. Hack
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Anne Ehret
- Universitätsklinikum Düsseldorf, Frauenklinik, Düsseldorf, Germany
| | - Daniel Gantert
- Universitätsklinikum Düsseldorf, Frauenklinik, Düsseldorf, Germany
| | | | | | - Jan Menke
- SHG-Kliniken Völklingen, Klinik für Radiologie, Völklingen, Germany
| | - Olaf Ortmann
- Arbeitsgemeinschaft Deutscher Tumorzentren, Germany
| | - Carmen Stromberger
- Charité – Universitätsmedizin Berlin, Klinik für Radioonkologie und Strahlentherapie, Berlin, Germany
| | - Karin Oechsle
- Universitätsklinikum Hamburg-Eppendorf, II. Medizinische Klinik und Poliklinik, Hamburg, Germany
| | - Beate Hornemann
- Universitätsklinikum Dresden, Psychoonkologischer Dienst, Dresden, Germany
| | - Friederike Mumm
- Medizinische Klinik und Poliklinik III und Comprehensive Cancer Center (CCC München LMU), Klinikum der Universität München, LMU München, München, Germany
| | - Christoph Grimm
- Abteilung für allgemeine Gynäkologie und gynäkologische Onkologie, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medizinische Universität Wien, Wien, Austria
| | - Alina Sturdza
- Universitätsklinikum AKH-Wien, Klinik für Radioonkologie, Wien, Austria
| | - Edward Wight
- Universitätsspital Basel, Frauenklinik, Basel, Switzerland
| | - Kristina Loessl
- Universitätsklinik Bern, Klinik für Radio-Onkologie, Bern, Switzerland
| | - Michael Golatta
- Universitätsklinikum Heidelberg, Frauenklinik, Heidelberg, Germany
| | - Volker Hagen
- St. Johannes Hospital Dortmund, Klinik für Innere Medizin II, Dortmund, Germany
| | - Timm Dauelsberg
- Universitätsklinikum Freiburg, Klinik für Onkologische Rehabilitation, Freiburg, Germany
| | - Ingo Diel
- Praxisklinik am Rosengarten, Mannheim, Germany
| | | | - Eberhard Merz
- Zentrum für Ultraschalldiagnostik und Pränatalmedizin Frankfurt, Frankfurt am Main, Germany
| | - Dirk Vordermark
- Universitätsklinikum Halle (Saale), Klinik für Strahlentherapie, Halle (Saale), Germany
| | - Katja Lindel
- Städtisches Klinikum Karlsruhe, Klinik für Radioonkologie und Strahlentherapie, Karlsruhe, Germany
| | | | | | - Ralph Lellé
- Universitätsklinikum Münster, Frauenklinik, Münster, Germany
| | - Klaus Neis
- Frauenärzte am Staden, Saarbrücken, Germany
| | | | | | | | | | | | | | | | | | | | - Ludwig Kiesel
- Universitätsklinikum Münster, Frauenklinik, Münster, Germany
| | - Michael Reinhardt
- Pius Hospital Oldenburg, Klinik für Nuklearmedizin, Oldenburg, Germany
| | - Michael Kreißl
- Universitätsklinikum Magdeburg, Klinik für Radiologie und Nuklearmedizin, Magdeburg, Germany
| | - Marianne Kloke
- Kliniken Essen-Mitte, Klinik für Palliativmedizin, Essen, Germany
| | | | - Regina Wiedemann
- Fliedner Fachhochschule Düsseldorf, Pflegewissenschaft, Düsseldorf, Germany
| | - Simone Marnitz
- Universitätsklinikum Köln, Klinik für Radioonkologie, Cyberknife- und Strahlentherapie, Köln, Germany
| | - Anne Letsch
- Universitätsklinikum Schleswig-Holstein, Klinik für Innere Medizin II, Kiel, Germany
| | - Isabella Zraik
- Kliniken Essen-Mitte, Klinik für Urologie, Essen, Germany
| | | | | | - Céline Alt
- Wolfgarten Radiologie Bonn, Bonn, Germany
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, Technische Universität Dresden and National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Peter Hillemanns
- Medizinische Hochschule Hannover, Frauenklinik, Hannover, Germany
| | - Kerstin Paradies
- Konferenz onkologischer Kranken- und Kinderkrankenpflege (KOK), Germany
| | | | | | - Ulla Henscher
- Deutscher Verband für Physiotherapie (ZVK) e. V., Germany
| | - Reina Tholen
- Deutscher Verband für Physiotherapie (ZVK) e. V., Germany
| | | | - Tanja Fehm
- Universitätsklinikum Düsseldorf, Frauenklinik, Düsseldorf, Germany
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15
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Fehm T, Stübs FA, Koch MC, Mallmann P, Dannecker C, Dietl A, Sevnina A, Mergel F, Lotz L, Ehret A, Gantert D, Martignoni F, Cieslik JP, Menke J, Ortmann O, Stromberger C, Oechsle K, Hornemann B, Mumm F, Grimm C, Sturdza A, Wight E, Loessl K, Golatta M, Hagen V, Dauelsberg T, Diel I, Münstedt K, Merz E, Vordermark D, Lindel K, Wittekind C, Küppers V, Lellé R, Neis K, Griesser H, Pöschel B, Steiner M, Freitag U, Gilster T, Schmittel A, Friedrich M, Haase H, Gebhardt M, Kiesel L, Reinhardt M, Kreißl M, Kloke M, Horn LC, Wiedemann R, Marnitz S, Letsch A, Zraik I, Mangold B, Möckel J, Alt C, Wimberger P, Hillemanns P, Paradies K, Mustea A, Denschlag D, Henscher U, Tholen R, Wesselmann S, Beckmann MW. Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) – Part 2 with Recommendations
on Psycho-oncology, Rehabilitation, Follow-up, Recurrence, Palliative Therapy and Healthcare Facilities. Geburtshilfe Frauenheilkd 2022; 82:181-205. [DOI: 10.1055/a-1671-2446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022] Open
Abstract
Abstract
Aim This is an update of the interdisciplinary S3-guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL), published in March 2021. The
work on the updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German
Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft
Gynäkologische Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG).
Method The process used to update the 2014 S3-guideline was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing
evidence-based national and international guidelines or – if evidence was lacking – on the consensus of the specialists involved in compiling the update. After an initial review of the
current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new
recommendations or statements which would take account of more recently published literature and the recent appraisal of new evidence.
Recommendations The short version of this guideline consists of recommendations and statements on palliative therapy and follow-up of patients with cervical cancer. The most
important aspects included in this updated guideline are the new FIGO classification published in 2018, the radical open surgery approach used to treat cervical cancer up to FIGO stage IB1,
and the use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided
adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.
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Affiliation(s)
- Tanja Fehm
- Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Frederik A. Stübs
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Martin C. Koch
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | | | | | - Anna Dietl
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Anna Sevnina
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Franziska Mergel
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Laura Lotz
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Anne Ehret
- Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | | | - Jan Menke
- SHG-Kliniken Völklingen, Klinik für Radiologie, Völklingen, Germany
| | - Olaf Ortmann
- Arbeitsgemeinschaft Deutscher Tumorzentren, Germany
| | - Carmen Stromberger
- Charité – Universitätsmedizin Berlin, Klinik für Radioonkologie und Strahlentherapie, Berlin, Germany
| | - Karin Oechsle
- Universitätsklinikum Hamburg-Eppendorf, II. Medizinische Klinik und Poliklinik, Hamburg, Germany
| | - Beate Hornemann
- Universitätsklinikum Dresden, Psychoonkologischer Dienst, Dresden, Germany
| | - Friederike Mumm
- Medizinische Klinik und Poliklinik III und Comprehensive Cancer Center (CCC München LMU), Klinikum der Universität München, LMU München, München, Germany
| | - Christoph Grimm
- Abteilung für allgemeine Gynäkologie und gynäkologische Onkologie, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medizinische Universität Wien, Wien, Austria
| | - Alina Sturdza
- Universitätsklinikum AKH-Wien, Klinik für Radioonkologie, Wien, Austria
| | - Edward Wight
- Universitätsspital Basel, Frauenklinik, Basel, Switzerland
| | - Kristina Loessl
- Universitätsklinik Bern, Klinik für Radio-Onkologie, Bern, Switzerland
| | - Michael Golatta
- Universitätsklinikum Heidelberg, Frauenklinik, Heidelberg, Germany
| | - Volker Hagen
- St. Johannes Hospital Dortmund, Klinik für Innere Medizin II, Dortmund, Germany
| | - Timm Dauelsberg
- Universitätsklinikum Freiburg, Klinik für Onkologische Rehabilitation, Freiburg, Germany
| | - Ingo Diel
- Praxisklinik am Rosengarten, Mannheim, Germany
| | | | - Eberhard Merz
- Zentrum für Ultraschalldiagnostik und Pränatalmedizin Frankfurt, Frankfurt am Main, Germany
| | - Dirk Vordermark
- Universitätsklinikum Halle (Saale), Klinik für Strahlentherapie, Halle (Saale), Germany
| | - Katja Lindel
- Städtisches Klinikum Karlsruhe, Klinik für Radioonkologie und Strahlentherapie, Karlsruhe, Germany
| | | | | | - Ralph Lellé
- Universitätsklinikum Münster, Frauenklinik, Münster, Germany
| | - Klaus Neis
- Frauenärzte am Staden, Saarbrücken, Germany
| | | | | | | | | | | | | | | | | | | | - Ludwig Kiesel
- Universitätsklinikum Münster, Frauenklinik, Münster, Germany
| | - Michael Reinhardt
- Pius Hospital Oldenburg, Klinik für Nuklearmedizin, Oldenburg, Germany
| | - Michael Kreißl
- Universitätsklinikum Magdeburg, Klinik für Radiologie und Nuklearmedizin, Magdeburg, Germany
| | - Marianne Kloke
- Kliniken Essen-Mitte, Klinik für Palliativmedizin, Essen, Germany
| | | | - Regina Wiedemann
- Fliedner Fachhochschule Düsseldorf, Pflegewissenschaft, Düsseldorf, Germany
| | - Simone Marnitz
- Universitätsklinikum Köln, Klinik für Radioonkologie, Cyberknife- und Strahlentherapie, Köln, Germany
| | - Anne Letsch
- Universitätsklinikum Schleswig-Holstein, Klinik für Innere Medizin II, Kiel, Germany
| | - Isabella Zraik
- Kliniken Essen-Mitte, Klinik für Urologie, Essen, Germany
| | | | | | - Céline Alt
- Wolfgarten Radiologie Bonn, Bonn, Germany
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, Technische Universität Dresden and National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Peter Hillemanns
- Medizinische Hochschule Hannover, Frauenklinik, Hannover, Germany
| | - Kerstin Paradies
- Konferenz onkologischer Kranken- und Kinderkrankenpflege (KOK), Germany
| | | | | | - Ulla Henscher
- Hochtaunus Kliniken, Frauenklinik, Bad Homburg, Germany
| | - Reina Tholen
- Deutscher Verband für Physiotherapie (ZVK) e. V., Germany
| | | | - Matthias W. Beckmann
- Universitätsklinikum Erlangen, Frauenklinik, Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Knoth J, Nesvacil N, Sturdza A, Kronreif G, Widder J, Kirisits C, Schmid MP. Toward 3D-TRUS image-guided interstitial brachytherapy for cervical cancer. Brachytherapy 2021; 21:186-192. [PMID: 34876361 DOI: 10.1016/j.brachy.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To qualitatively and quantitatively analyze needle visibility in combined intracavitary and interstitial cervical cancer brachytherapy on 3D transrectal ultrasound (TRUS) in comparison to gold standard MRI. METHODS AND MATERIALS Image acquisition was done with a customized TRUS stepper unit and software (Medcom, Germany; Elekta, Sweden; ACMIT, Austria) followed by an MRI on the same day with the applicator in place. Qualitative assessment was done with following scoring system: 0 = no visibility 1 (= poor), 2 (= fair), 3 (= excellent) discrimination, quantitative assessment was done by measuring the distance between each needle and the tandem two centimeters (cm) above the ring and comparing to the respective measurement on MRI. RESULTS Twenty-nine implants and a total of 188 needles (132 straight, 35 oblique, 21 free-hand) were available. Overall, 79% were visible (87% straight, 51% oblique, 76% free-hand). Mean visibility score was 1.4 ± 0.5 for all visible needles. Distance of the visible needles to tandem was mean ± standard deviation (SD) 21.3 millimeters (mm) ± 6.5 mm on MRI and 21.0 mm ± 6.4 mm on TRUS, respectively. Difference between MRI and TRUS was max 14 mm, mean ± SD -0.3 mm ± 2.6 mm. 11% differed more than 3 mm. CONCLUSIONS Straight needles were better detectable than oblique needles (87% vs. 51%). Detectability was impaired by insufficient rotation of the TRUS probe, poor image quality or anatomic variation. As needles show a rather indistinct signal on TRUS, online detection with a standardized imaging protocol in combination with tracking should be investigated, aiming at the development of real time image guidance and online treatment planning.
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Affiliation(s)
- Johannes Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Gernot Kronreif
- Austrian Center for Medical Innovation and Technology, Wr. Neustadt, Austria
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maximilian Paul Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
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17
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Smet S, Spampinato S, Pötter R, Jürgenliemk-Schulz IM, Nout RA, Chargari C, Mahantshetty U, Sturdza A, Segedin B, Bruheim K, Hoskin P, Rai B, Huang F, Cooper R, Van der Steen-Banasik E, Sundset M, Van Limbergen E, Tan LT, Lutgens LCHW, Villafranca E, Pieters BR, Tanderup K, Kirchheiner K. Risk factors for late persistent fatigue after chemoradiotherapy in locally advanced cervical cancer: an analysis from the EMBRACE-I study. Int J Radiat Oncol Biol Phys 2021; 112:1177-1189. [PMID: 34838868 DOI: 10.1016/j.ijrobp.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 11/17/2022]
Abstract
Objective To evaluate patient- and treatment-related risk factors for late persistent fatigue within the prospective, multi-center XXX study. Methods Fatigue was prospectively assessed (CTCAE v.3) at baseline and during regular follow-up in 993 locally advanced cervical cancer patients, after treatment with chemoradiotherapy and MRI-guided brachytherapy. Risk factors for baseline and late persistent fatigue were evaluated with multivariable logistic regression. Late persistent fatigue was defined, when either G≥1 or G≥2 was scored in at least half of follow-ups. Results Median follow-up was 57 months. Baseline fatigue G≥1/G≥2 (35.8%/6.3%, respectively) was associated with pre-existing co-morbidities, WHO Performance Status, underweight, severe pain and tumor volume. Late persistent G≥1/G≥2 fatigue (36.3%/5.8%, respectively) was associated with patient-related factors (baseline fatigue, younger age, obesity), alongside the size of irradiated volumes and the level of radiation doses from external beam radiotherapy (EBRT) and brachytherapy (EBRT: V43Gy, V57Gy; EBRT+brachytherapy: V60Gy EQD2). Large volume lymph node (LN) boost compared to no LN boost, increased the risk for late persistent fatigue G≥2 by 18% and 5% (in patients with and without baseline fatigue, respectively). The risk for late persistent fatigue G≥1 increased by 7% and 4% with V43Gy <2000cm³ versus >3000cm³ (in patients with and without baseline fatigue, respectively). Late persistent G≥1 fatigue occurred in 13% of patients without late persistent organ-related symptoms (gastro-intestinal, genito-urinary and vaginal), versus 34-43%, 50-58% and 73% in patients suffering from persistent symptoms involving 1,2 or 3 organs, respectively. Conclusion Late persistent fatigue occurs in a considerable number of patients after chemoradiotherapy. It is associated with patient-related factors, the size of volumes irradiated to intermediate and high EBRT and brachytherapy doses, and other persistent organ-related morbidity. These findings support the importance of ongoing efforts to better tailor the target dose and reduce irradiation of healthy tissue without compromising target coverage, using highly conformal EBRT and brachytherapy techniques.
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Affiliation(s)
- Stéphanie Smet
- Department of Radiation Oncology, AZ Turnhout, Turnhout, Belgium; Iridium Cancer Network, Antwerp, Belgium
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Hospital of Vienna, Vienna, Austria
| | | | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India; Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, India
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Hospital of Vienna, Vienna, Austria
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, Maastricht, The Netherlands
| | - Elena Villafranca
- Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Hospital of Vienna, Vienna, Austria.
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18
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Spampinato S, Jensen NBK, Pötter R, Fokdal LU, Chargari C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Hoskin P, Segedin B, Rai B, Bruheim K, Wiebe E, Van der Steen-Banasik E, Cooper R, Van Limbergen E, Sundset M, Pieters BR, Lutgens LCHW, Tan LT, Villafranca E, Smet S, Jastaniyah N, Nout RA, Kirisits C, Chopra S, Kirchheiner K, Tanderup K. Severity and persistency of late gastrointestinal morbidity in locally advanced cervical cancer: lessons learned from EMBRACE-I and implications for the future. Int J Radiat Oncol Biol Phys 2021; 112:681-693. [PMID: 34678431 DOI: 10.1016/j.ijrobp.2021.09.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate patient- and treatment-related risk factors for physician-assessed and patient-reported gastrointestinal (GI) symptoms after radio(chemo)therapy and image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer (LACC). MATERIAL AND METHODS Of 1416 patients from the XXX study, 1199 and 1002 were prospectively evaluated using physician-assessed (CTCAE) and patient-reported (EORTC) GI symptoms, respectively. CTCAE severe grade (G≥3) events were pooled according to the location in the GI tract (anus/rectum, sigmoid and colon/small bowel). CTCAE G≥2 and EORTC "very much" and "quite a bit"+"very much" scores (≥"quite a bit") were analyzed for individual symptoms with Cox regression. Logistic regression was used for persistent G≥1 and EORTC ≥"quite a bit" symptoms, defined if present in at least half of follow-ups. RESULTS Incidence of G≥3 events was 2.8%, 1.8% and 2.3% for G≥3 anus/rectum, sigmoid and colon/small bowel events, respectively. Among G≥2 symptoms, diarrhea and flatulence were the most prevalent (8.4% and 9.9%, respectively). Among patient-related factors, baseline morbidity, increasing age, smoking status and low body-mass-index were associated to GI symptoms with different impact. Among treatment-related factors, rectum D2cm3 and ICRU recto-vaginal reference point (RV-RP) correlated with G≥3 anus/rectum events, and moderate/persistent diarrhea, proctitis, bleeding, abdominal cramps and difficulty in bowel control. Bowel D2cm3 correlated with G≥3 sigmoid and colon/small bowel events, and moderate/persistent diarrhea and flatulence. For external beam radiotherapy (EBRT), prescription dose correlated with G≥3 anus/rectum, diarrhea and difficulty in bowel control. Patients with large lymph-node boost (V57Gy) were at higher risk for G≥3 sigmoid events, moderate/persistent diarrhea, proctitis and cramps. CONCLUSION The analysis showed that both EBRT and IGABT contribute to GI symptoms after LACC treatment. Rectum D2cm3, ICRU RV-RP and bowel D2cm3 are risk factors for GI morbidity. The risk for various symptoms was lower with an EBRT prescription of 45Gy than 50Gy, and increased with larger V57Gy.
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Affiliation(s)
- Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Umesh Mahantshetty
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia; Faculty of medicine, University of Ljubljana
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo Norway
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | | | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, Maastricht, The Netherlands
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Elena Villafranca
- Department of Radiation Oncology, Hospital of Navarra, Pamplona, Spain
| | - Stéphanie Smet
- Department of Radiation Oncology, Algemeen Ziekenhuis Turnhout, Turnhout, Belgium
| | - Noha Jastaniyah
- Radiation Oncology Section, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Remi A Nout
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
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19
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Peters M, de Leeuw AAC, Nomden CN, Tanderup K, Kirchheiner K, Lindegaard JC, Kirisits C, Haie-Meder C, Sturdza A, Fokdal L, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Huang F, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters BR, Tan LT, van Rossum PSN, Nesvacil N, Nout R, Schmid MP, Pötter R, Jürgenliemk-Schulz IM. Risk factors for nodal failure after radiochemotherapy and image guided brachytherapy in locally advanced cervical cancer: An EMBRACE analysis. Radiother Oncol 2021; 163:150-158. [PMID: 34480958 DOI: 10.1016/j.radonc.2021.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess risk factors for nodal failure (NF) after definitive (chemo)radiotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) for patients treated in the EMBRACE I study. MATERIALS AND METHODS Data for pelvic NF and para-aortic (PAO) NF (NFPAO) were analysed. After multiple imputation, univariable and multivariable Cox-regression was performed for clinical and treatment-related variables. For patients with affected pelvic nodes but no PAO nodes at diagnosis, additional analyses were performed for two subgroups: 1. 'small pelvis' nodes in internal and external iliac, obturator, parametrial, presacral and/or common iliac (CI) region and 2. any CI nodes (subgroup of 1). RESULTS 1338 patients with 152 NF and 104 NFPAO events were analysed with a median follow-up of 34.2 months (IQR 16.4-52.7). For the entire group, larger tumour width, nodal risk groups (in particular any CI nodes without PAO nodes), local failure, and lower Hb-nadir increased the risk of NF. Elective PAO-irradiation was independently associated with a decreased risk of NFPAO (HR 0.53, 95%-CI 0.28-1.00, p = 0.05). For subgroup 1, having 'any CI nodes without PAO nodes' and local failure significantly increased NF risk. Additionally, elective PAO-irradiation was associated with less risk of NFPAO (HR 0.38, 95%-CI 0.17-0.86, p = 0.02). For subgroup 2 only local failure was associated with higher risk of NF. CONCLUSION In this patient cohort, nodal disease and tumour width at diagnosis, as well as local failure, are risk factors for NF after definitive treatment. Having either 'any PAO nodes' (with or without pelvic nodes) or 'any CI nodes' (without PAO nodes) are stronger risk factors than involvement of nodes in the small pelvis alone. Elective PAO-irradiation was associated with significantly less NFPAO, particularly in patients with nodal disease in the 'small pelvis' and/or CI region at time of diagnosis.
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Affiliation(s)
- Max Peters
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| | - Astrid A C de Leeuw
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Christel N Nomden
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Lars Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | | | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Barbara Segedin
- Institute of Oncology Ljubljana, Department of Radiotherapy, Ljubljana, Slovenia
| | - Kjersti Bruheim
- The Norwegian Radium Hospital-Oslo University Hospital, Department of Oncology, Oslo, Norway
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Department of Radiotherapy and Oncology, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Li Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom
| | - Peter S N van Rossum
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Remi Nout
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
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20
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Kirchheiner K, Smet S, Jürgenliemk-Schulz IM, Haie-Meder C, Chargari C, Lindegaard JC, Fokdal LU, Spampinato S, Schmid MP, Sturdza A, Mahantshetty U, Segedin B, Bruheim K, Rai B, Cooper R, Van der Steen-Banasik E, Wiebe E, Sundset M, van Limbergen E, Villafranca E, Westerveld H, Tan LT, Pötter R, Tanderup K, Nout RA. Impact of Vaginal Symptoms and Hormonal Replacement Therapy on Sexual Outcomes After Definitive Chemoradiotherapy in Patients With Locally Advanced Cervical Cancer: Results from the EMBRACE-I Study. Int J Radiat Oncol Biol Phys 2021; 112:400-413. [PMID: 34478833 DOI: 10.1016/j.ijrobp.2021.08.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate patient-reported sexual outcomes after chemoradiation therapy and image-guided adaptive brachytherapy for locally advanced cervical cancer in the observational, prospective, multicenter EMBRACE-I study. METHODS AND MATERIALS Sexual outcomes were assessed prospectively with the European Organization for Research and Treatment of Cancer Qualify of Life Questionnaire (EORTC-QLQ-CX24) at baseline and follow-up. Crude incidence and prevalence rates of sexual activity, vaginal functioning problems (dryness, shortening, tightening, pain during intercourse), and sexual enjoyment were evaluated. Associations between pain during intercourse and vaginal functioning problems or sexual enjoyment were calculated, pooling observations over all follow-ups (Spearman correlation coefficient). In patients who were frequently sexually active (≥50% of follow-ups), the effects of regular hormonal replacement therapy (HRT) on vaginal functioning problems were evaluated (Pearson χ2). RESULTS The analysis involved 1045 patients with a median follow-up of 50 months. Sexual activity was reported by 22% of patients at baseline and by 40% to 47% of patients during follow-up (prevalence rates). Vaginal functioning problems in follow-up were dryness (18%-21%), shortening (15%-22%), tightening (16%-22%), pain during intercourse (9%-21%), and compromised enjoyment (37%-47%). Pain during intercourse was significantly associated with vaginal tightening (r = 0.544), shortening (r = 0.532), and dryness (r = 0.408) and negatively correlated with sexual enjoyment (r = -0.407). Regular HRT was associated with significantly less vaginal dryness (P = .015), shortening (P = .024), pain during intercourse (P = .003), and borderline higher sexual enjoyment (P = .062). CONCLUSIONS Vaginal functioning problems are associated with pain and compromised sexual enjoyment. Further effort is required for the primary prevention of vaginal morbidity with dose optimization and adaptation. Secondary prevention strategies, including HRT for vaginal and sexual health after radiation therapy in locally advanced cervical cancer, should be considered and sexual rehabilitation programs should be developed further.
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Affiliation(s)
- Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Stéphanie Smet
- Department of Radiation Oncology, AZ Turnhout, Turnhout, Belgium; Iridium Cancer Network, Antwerp, Belgium
| | | | | | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | | | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Homi Bhabha National Institute, India
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Erik van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Elena Villafranca
- Department of Radiation Oncology, Hospital of Navarra, Pamplona, Spain
| | - Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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Sturdza A, Stephanides M, Eriksen J, Benstead K, Hoskin P, Vlad S, Escande A, Corradini S, Konrad S, Westerveld H, Tagliaferri L, Najjari D, Konat-Bąska K, Plesinac Karapandzic V, Tan L, Nout R, Peters B, Tanderup K, Jürgenliemk-Schulz I, Kamrava M. PO-1487 Brachytherapy training survey among Radiation Oncology residents in Europe. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07938-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Ecker S, Kirisits C, Seppenwoolde Y, De Leeuw A, Schmid M, Sturdza A, Knoth J, Pötter R, Tanderup K, Nout R, Nesvacil N. OC-0427 Statistical monitoring for a large multi-institutional clinical study in radiation oncology. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Knoth J, Nesvacil N, Sturdza A, Kronreif G, Widder J, Kirisits C, Schmid M. PP-0141 Assessment of interstitial needles with 3D-TRUS in cervical cancer brachytherapy. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lindegaard J, Petric P, Schmid M, Haie-Meder C, Fokdal L, Sturdza A, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, van der Steen-Banasik E, Van Limbergen E, Pieters B, Tan L, Nout R, de Leeuw A, Nesvacil N, Kirchheiner K, Jürgenliemk-Schultz I, Tanderup K, Kirisits C, Pötter R, Collaborative Group E. OC-0025 Tumor regression of cervical cancer during chemoradiation evaluated by the T-score in EMBRACE I. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06277-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sturdza A. SP-0076 Motivating the next generation of brachytherapy trainees. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06490-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, Ledermann J, Bosse T, Chargari C, Fagotti A, Fotopoulou C, Martin AG, Lax S, Lorusso D, Marth C, Morice P, Nout RA, O'Donnell D, Querleu D, Raspollini MR, Sehouli J, Sturdza A, Taylor A, Westermann A, Wimberger P, Colombo N, Planchamp F, Creutzberg CL. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Radiother Oncol 2021; 154:327-353. [PMID: 33712263 DOI: 10.1016/j.radonc.2020.11.018] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide. ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives. The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.
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Affiliation(s)
- Nicole Concin
- Department of Gynecology and Obstetrics, Innsbruck Medical University, Austria; Evangelische Kliniken Essen-Mitte, Germany.
| | - Xavier Matias-Guiu
- Department of Pathology, Hospital Universitari Arnau de Vilanova, University of Lleida, CIBERONC, Irblleida, Spain; Department of Pathology, Hospital Universitari de Bellvitge, University of Barcelona, Idibell, Spain
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Belgium
| | - David Cibula
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Czech Republic
| | - Mansoor Raza Mirza
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Simone Marnitz
- Department of Radiation Oncology, Medical Faculty of the University of Cologne, Germany
| | | | - Tjalling Bosse
- Department of Pathology, Leids Universitair Medisch Centrum, Leiden, Netherlands
| | - Cyrus Chargari
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Christina Fotopoulou
- Department of Gynaecologic Oncology, Imperial College London Faculty of Medicine, UK
| | | | - Sigurd Lax
- Department of Pathology, Hospital Graz II, Austria; School of Medicine, Johannes Kepler University Linz, Austria
| | - Domenica Lorusso
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Austria
| | - Philippe Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Denis Querleu
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
| | - Maria Rosaria Raspollini
- Histopathology and Molecular Diagnostics, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Germany
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | | | - Anneke Westermann
- Department of Medical Oncology, Amsterdam University Medical Centres, Noord-Holland, Netherlands
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, TU Dresden Medizinische Fakultat Carl Gustav Carus, Germany
| | - Nicoletta Colombo
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, Milan and University of Milan-Bicocca, Italy
| | | | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden Netherlands
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Westerveld H, Schmid MP, Nout RA, Chargari C, Pieters BR, Creutzberg CL, Sturdza A, Lindegaard JC, van Kesteren Z, Mazeron R, Nesvacil N, Fokdal LU. Image-Guided Adaptive Brachytherapy (IGABT) for Primary Vaginal Cancer: Results of the International Multicenter RetroEMBRAVE Cohort Study. Cancers (Basel) 2021; 13:1459. [PMID: 33806733 PMCID: PMC8004779 DOI: 10.3390/cancers13061459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE This study assessed outcomes following the nowadays standing treatment for primary vaginal cancer with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT) in a multicenter patient cohort. METHODS Patients treated with computer tomography (CT)-MRI-assisted-based IGABT were included. Retrospective data collection included patient, tumor and treatment characteristics. Late morbidity was assessed by using the CTCAE 3.0 scale. RESULTS Five European centers included 148 consecutive patients, with a median age of 63 years. At a median follow-up of 29 months (IQR 25-57), two- and five-year local control were 86% and 83%; disease-free survival (DFS) was 73% and 66%, and overall survival (OS) was 79% and 68%, respectively. Crude incidences of ≥ grade-three urogenital, gastro-intestinal and vaginal morbidity was 8%, 3% and 8%, respectively. Lymph node metastasis was an independent prognostic factor for disease-free survival (DFS). Univariate analysis showed improved local control in patients with T2-T4 tumors if >80 Gy EQD2α/β10 was delivered to the clinical target volume (CTV) at the time of brachytherapy. CONCLUSIONS In this large retrospective multicenter study, IGABT for primary vaginal cancer resulted in a high local control with acceptable morbidity. These results compared favorably with two-dimensional (2D) radiograph-based brachytherapy and illustrate that IGABT plays an important role in the treatment of vaginal cancer.
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Affiliation(s)
- Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Maximilian P. Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Remi A. Nout
- Department of Radiation Oncology, Leiden University Medical Center, 2333 Leiden, The Netherlands; (R.A.N.); (C.L.C.)
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 Rotterdam, The Netherlands
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Université Paris Saclay, 94805 Villesuif, France;
| | - Bradley R. Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Carien L. Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, 2333 Leiden, The Netherlands; (R.A.N.); (C.L.C.)
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Jacob C. Lindegaard
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (J.C.L.); (L.U.F.)
| | - Zdenko van Kesteren
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Université Paris Saclay, 94805 Villesuif, France;
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Lars U. Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (J.C.L.); (L.U.F.)
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28
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Spampinato S, Fokdal LU, Pötter R, Haie-Meder C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Segedin B, Bruheim K, Hoskin P, Rai B, Huang F, Cooper R, van der Steen-Banasik E, Van Limbergen E, Sundset M, Westerveld H, Nout RA, Jensen NBK, Kirisits C, Kirchheiner K, Tanderup K. Risk factors and dose-effects for bladder fistula, bleeding and cystitis after radiotherapy with imaged-guided adaptive brachytherapy for cervical cancer: An EMBRACE analysis. Radiother Oncol 2021; 158:312-320. [PMID: 33545254 DOI: 10.1016/j.radonc.2021.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE To identify patient- and treatment-related risk factors for fistula, bleeding, cystitis, pain and difficulty in voiding in locally advanced cervical cancer patients treated with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT). MATERIAL AND METHODS Morbidity within the EMBRACE-I study was prospectively reported for physician-assessed (CTCAE) fistula, bleeding and cystitis and patient-reported (EORTC) pain and difficulty in voiding. Analysis of risk factors was performed in patients without bladder infiltration. Risk factors were tested with Cox regression for grade (G) ≥ 3 cystitis, for G ≥ 2 fistula, bleeding and cystitis, and for EORTC "very much" and "quite a bit" or worse. RESULTS Of 1416 patients enrolled, 1153 and 884 patients without bladder infiltration were evaluable for the analysis of CTCAE and EORTC items, respectively. Median follow-up was 48[3-120] months. Crude incidence rates for G ≥ 2 fistula, bleeding and cystitis were 0.7%, 2.7% and 8.8%, respectively, and 16% and 14% for "quite a bit" or worse pain and difficulty in voiding, respectively. Baseline urinary morbidity and overweight/obesity were significant risk factors for most endpoints. Bladder D2cm3 correlated with G ≥ 2 fistula, bleeding and cystitis, while ICRU bladder point dose correlated with EORTC pain "quite a bit" or worse. An increase from 75 Gy to 80 Gy in bladder D2cm3 resulted in an increase from 8% to 13% for 4-year actuarial estimate of G ≥ 2 cystitis. CONCLUSION Clinical and treatment-related risk factors for bladder fistula, bleeding and cystitis were identified within a prospective and multi-institutional setting. A dose-effect was established with bladder D2cm3, reinforcing the importance of continued optimization during individualized IGABT planning.
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Affiliation(s)
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | | | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | | | | | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, The Norwegian Radium Hospital - Oslo University Hospital, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, United Kingdom
| | | | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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29
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Oberndorfer F, Moling S, Hagelkruys LA, Grimm C, Polterauer S, Sturdza A, Aust S, Reinthaller A, Müllauer L, Schwameis R. Risk Reclassification of Patients with Endometrial Cancer Based on Tumor Molecular Profiling: First Real World Data. J Pers Med 2021; 11:jpm11010048. [PMID: 33467460 PMCID: PMC7830511 DOI: 10.3390/jpm11010048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Recently, guidelines for endometrial cancer (EC) were released that guide treatment decisions according to the tumors’ molecular profiles. To date, no real-world data regarding the clinical feasibility of molecular profiling have been released. This retrospective, monocentric study investigated the clinical feasibility of molecular profiling and its potential impact on treatment decisions. Tumor specimens underwent molecular profiling (testing for genetic alterations, (immune-)histological examination of lymphovascular space invasion (LVSI), and L1CAM) as part of the clinical routine and were classified according to the European Society for Medical Oncology (ESMO) classification system and to an integrated molecular risk stratification. Shifts between risk groups and potential treatment alterations are described. A total of 60 cases were included, of which twelve were excluded (20%), and eight of the remaining 48 were not characterized (drop-out rate of 16.7%). Molecular profiling revealed 4, 6, 25, and 5 patients with DNA polymerase-epsilon mutation, microsatellite instability, no specific molecular profile, and TP53 mutation, respectively. Three patients had substantial LVSI, and four patients showed high L1CAM expression. Molecular profiling took a median of 18.5 days. Substantial shifts occurred between the classification systems: four patients were upstaged, and 19 patients were downstaged. Molecular profiling of EC specimens is feasible in a daily routine, and new risk classification systems will change treatment decisions substantially.
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Affiliation(s)
- Felicitas Oberndorfer
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (F.O.); (L.A.H.); (L.M.)
| | - Sarah Moling
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.M.); (S.P.); (S.A.); (A.R.); (R.S.)
| | - Leonie Annika Hagelkruys
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (F.O.); (L.A.H.); (L.M.)
| | - Christoph Grimm
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.M.); (S.P.); (S.A.); (A.R.); (R.S.)
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-29150
| | - Stephan Polterauer
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.M.); (S.P.); (S.A.); (A.R.); (R.S.)
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, 1090 Vienna, Austria
| | - Alina Sturdza
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Stefanie Aust
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.M.); (S.P.); (S.A.); (A.R.); (R.S.)
| | - Alexander Reinthaller
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.M.); (S.P.); (S.A.); (A.R.); (R.S.)
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, 1090 Vienna, Austria
| | - Leonhard Müllauer
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (F.O.); (L.A.H.); (L.M.)
| | - Richard Schwameis
- Comprehensive Cancer Center, Gynecologic Cancer Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.M.); (S.P.); (S.A.); (A.R.); (R.S.)
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, 1090 Vienna, Austria
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30
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Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, Ledermann J, Bosse T, Chargari C, Fagotti A, Fotopoulou C, Gonzalez Martin A, Lax S, Lorusso D, Marth C, Morice P, Nout RA, O'Donnell D, Querleu D, Raspollini MR, Sehouli J, Sturdza A, Taylor A, Westermann A, Wimberger P, Colombo N, Planchamp F, Creutzberg CL. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer 2020; 31:12-39. [PMID: 33397713 DOI: 10.1136/ijgc-2020-002230] [Citation(s) in RCA: 735] [Impact Index Per Article: 183.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
A European consensus conference on endometrial carcinoma was held in 2014 to produce multi-disciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.
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Affiliation(s)
- Nicole Concin
- Department of Gynecology and Obstetrics, Innsbruck Medical University, Innsbruck, Austria .,Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - Xavier Matias-Guiu
- Department of Pathology, Hospital Universitari Arnau de Vilanova, University of Lleida, CIBERONC, Irblleida, Spain.,Department of Pathology, Hospital Universitari de Bellvitge, University of Barcelona, Idibell, Spain
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - David Cibula
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - Mansoor Raza Mirza
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simone Marnitz
- Department of Radiation Oncology, Medical Faculty of the University of Cologne, Cologne, Germany
| | | | - Tjalling Bosse
- Department of Pathology, Leids Universitair Medisch Centrum, Leiden, Netherlands
| | - Cyrus Chargari
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Christina Fotopoulou
- Department of Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, UK
| | | | - Sigurd Lax
- Department of Pathology, Hospital Graz II, Graz, Austria.,School of Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Domenica Lorusso
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Philippe Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Denis Querleu
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
| | - Maria Rosaria Raspollini
- Histopathology and Molecular Diagnostics, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Anneke Westermann
- Department of Medical Oncology, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, Netherlands
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, TU Dresden Medizinische Fakultat Carl Gustav Carus, Dresden, Germany
| | - Nicoletta Colombo
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, Milan and University of Milan-Bicocca, Milan, Italy
| | | | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands
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Chopra S, Mangaj A, Sharma A, Tan LT, Sturdza A, Jürgenliemk-Schulz I, Han K, Huang F, Schmid MP, Fokdal L, Chargari C, Diendorfer T, Tanderup K, Potter R, Nout RA. Management of oligo-metastatic and oligo-recurrent cervical cancer: A pattern of care survey within the EMBRACE research network. Radiother Oncol 2020; 155:151-159. [PMID: 33144247 DOI: 10.1016/j.radonc.2020.10.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the metastatic or recurrent cervical cancer, systemic chemotherapy constitutes the main treatment. Though there is an increasing use of high dose external radiation and brachytherapy in the metastatic setting, no consensus exists. METHODS A 17-item survey was designed with additional case-based questions to explore present management of oligo-metastatic and oligo-recurrent cervix cancer within EMBRACE research group participating sites. The questions were designed to elicit prevailing practices in the management of de-novo oligo-metastasis and oligo-recurrent setting after completing the primary treatment of cervix cancer. The survey was sent electronically with two rounds of email reminders to respond over a 2-week survey period. The online survey was designed such that it was mandatory to complete all questions. The responses were recorded and results were summarized as proportions and summary statistics were generated. RESULTS Twenty-two centers responded to this survey. A majority (90%) of respondents reported a low incidence of de-novo oligo-metastatic cervical cancer in their practice (<5%), with a higher proportion of patients with oligo-recurrence after completing primary treatment (5-10%). All responding sites preferred to treat pelvic disease in the de-novo oligo-metastatic setting albeit with different fractionation regimens. While 68.2% of respondents recommended chemo-radiation and brachytherapy, 31.8% considered additional systemic therapy. Overall 77.3% centers recommended the use of stereotactic ablative radiation therapy to oligo-metastasis. For out-of-field nodal recurrences, 63.7% of respondents considered treating with curative intent, while 59% preferred treating in-field recurrence with palliative intent. A vast majority of the participating centers (90%) have stereotactic radiation therapy capacity and would consider a clinical trial addressing oligo-metastatic and oligo-recurrent cervical cancer. CONCLUSION Although contemporary practice is variable, a substantial proportion of EMBRACE centers consider high dose radiation in de-novo metastatic and oligo-recurrence settings. However, there is clear need for a joint clinical protocol and prospective studies to address the role of high dose radiation within oligo-recurrent and oligo-metastatic scenarios.
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Affiliation(s)
- Supriya Chopra
- Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India.
| | - Akshay Mangaj
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Alisha Sharma
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Li Tee Tan
- Cambridge University Addenbrooke's Hospital, United Kingdom
| | - Alina Sturdza
- Medical University/General Hospital of Vienna, Comprehensive Cancer Center, Austria
| | | | - Kathy Han
- University of Toronto Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Fleur Huang
- Cross Cancer Institute and University of Alberta, Department of Oncology, Edmonton, Canada
| | - Maximilian P Schmid
- Medical University/General Hospital of Vienna, Comprehensive Cancer Center, Austria
| | - Lars Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | | | - Tamara Diendorfer
- Medical University/General Hospital of Vienna, Comprehensive Cancer Center, Austria
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Richard Potter
- Medical University/General Hospital of Vienna, Comprehensive Cancer Center, Austria
| | - Remi A Nout
- Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, the Netherlands.
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Schmid M, Kirisits C, Tanderup K, Haie-Meder C, Fokdal L, Sturdza A, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Pieters B, Tan L, Nout R, De Leeuw A, Nesvacil N, Jürgenliemk-Schulz I, Lindegaard J, Pötter R. OC-1051: Local failure in cervical cancer patients after MR image-guided adaptive brachytherapy. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01988-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pötter R, Tanderup K, Schmid M, Haie-Meder C, Fokdal L, Sturdza A, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Pieters B, Tan L, Nout R, De Leeuw A, Nesvacil N, Kirchheiner K, Jürgenliemk-Schulz I, Kirisits C, Lindegaard J, Embrace C. OC-0437: MRI guided adaptive brachytherapy in locally advanced cervical cancer: overall results of EMBRACE I. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00459-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jensen N, Pötter R, Fokdal L, Chargari C, Lindegaard J, Schmid M, Sturdza A, Mahantshetty U, Jürgenliemk-Schulz I, Hoskin P, Segedin B, Rai B, Bruheim K, Wiebe E, Van der Steen-Banasik E, Cooper R, Van Limbergen E, Sundset M, Pieters B, Nout R, Kirisits C, Kirchheiner K, Tanderup K. PH-0404: Risk factors for late diarrhoea after radio(chemo)therapy in cervical cancer: EMBRACE I results. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00426-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Peters M, De Leeuw A, Pötter R, Nomden C, Tanderup K, Kirchheiner K, Schmid M, Fortin I, Haie-Meder C, Lindegaard J, Sturdza A, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Huang F, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Nout R, Jürgenliemk-Schulz I. OC-0566: Risk factors for nodal failure in the EMBRACE study cohort. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Vittrup A, Kirchheiner K, Tanderup K, Jensen N, Spampinato S, Fokdal L, Kirisits C, Haie-Meder C, Lindegaard J, Schmid M, Sturdza A, Mahantshetty U, Jürgenliemk-Schulz I, Hoskin P, Segedin B, Bruheim K, Rai B, Wiebe E, Van der Steen-Banasik E, Cooper R, Van Limbergen E, Sundset M, Pieters B, Nout R, Pötter R. OC-0569: Incidence of severe gastrointestinal and urinary fistulas, bleeding and strictures: EMBRACE results. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00591-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Spampinato S, Fokdal LU, Pötter R, Haie-Meder C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Segedin B, Bruheim K, Hoskin P, Rai B, Huang F, Cooper R, van der Steen-Banasik E, Van Limbergen E, Sundset M, Westerveld H, Nout RA, Jensen NBK, Kirisits C, Kirchheiner K, Tanderup K. Importance of the ICRU bladder point dose on incidence and persistence of urinary frequency and incontinence in locally advanced cervical cancer: An EMBRACE analysis. Radiother Oncol 2020; 158:300-308. [PMID: 33065183 DOI: 10.1016/j.radonc.2020.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/25/2020] [Accepted: 10/02/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify patient- and treatment-related risk factors and dose-effects for urinary frequency and incontinence in locally advanced cervical cancer (LACC) treated with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT). MATERIAL AND METHODS Physician-assessed (CTCAE) and patient-reported (EORTC) frequency and incontinence recorded in the EMBRACE-I study were analysed. Risk factors analysis was performed in patients without bladder infiltration and with baseline morbidity available. Cox regression was used for CTCAE grade (G) ≥ 3 and G ≥ 2 and for EORTC "very much" and "quite a bit" or worse. Logistic regression was used for late persistent morbidity defined when CTCAE G ≥ 1 or EORTC ≥ "quite a bit" were scored in at least half of follow-ups. RESULTS Longitudinal data on 1153 and 884 patients were available for CTCAE and EORTC analysis, respectively. Median follow-up was 48[3-120] months. Crude incidence rates of G≥2 were 13% and 11% for frequency and incontinence, respectively. Baseline morbidity and overweight-obesity were risk factors for both symptoms. Elderly patients were at higher risk for incontinence. Patients receiving conformal-radiotherapy were at higher risk for frequency. ICRU bladder point (ICRU-BP) dose was a stronger predictor for incontinence than bladder D2cm3. The 5-year actuarial estimate of G ≥ 2 incontinence increased from 11% to 20% with ICRU-BP doses > 75 Gy compared to ≤ 65 Gy. Frequency showed weaker associations with dose. CONCLUSION ICRU-BP dose, in addition to clinical parameters, is a risk factor for urinary incontinence and shows a dose-effect after radio(chemo)therapy and IGABT. ICRU-BP dose should be monitored during treatment planning alongside volumetric parameters. Frequency seems associated with larger irradiated volumes.
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Affiliation(s)
- Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | | | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, The Norwegian Radium Hospital - Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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K Jensen NB, Pötter R, Spampinato S, Fokdal LU, Chargari C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Segedin B, Bruheim K, Hoskin P, Rai B, Wiebe E, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Sundset M, Pieters BR, Nout RA, Kirisits C, Kirchheiner K, Tanderup K. Dose-Volume Effects and Risk Factors for Late Diarrhea in Cervix Cancer Patients After Radiochemotherapy With Image Guided Adaptive Brachytherapy in the EMBRACE I Study. Int J Radiat Oncol Biol Phys 2020; 109:688-700. [PMID: 33068689 DOI: 10.1016/j.ijrobp.2020.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate patient- and treatment-related risk factors associated with incidence and persistence of late diarrhea after radiochemotherapy and image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. MATERIALS AND METHODS Of 1416 patients from the EMBRACE I study, 1199 were prospectively evaluated using physician-reported (Common Terminology Criteria for Adverse Events version 3 [CTCAEv3]) assessment for diarrhea; median follow-up 48 months. Patient-reported outcome (EORTC) was available in 900 patients. Incidence of CTCAE G≥2, G≥3, and EORTC "very much" diarrhea was analyzed with Cox proportional hazards regression. Binary logistic regression was used for analysis of persistent G≥1 and EORTC "quite a bit" - "very much" (≥"quite a bit") diarrhea, defined if present in at least half of all follow-ups. RESULTS Crude incidences of G≥2 and G≥3 diarrhea were 8.3% and 1.5%, respectively, and 8% of patients reported "very much" diarrhea. Persistent G≥1 and ≥"quite a bit" diarrhea was present in 16% and 7%, respectively. Patient-related risk factors were baseline diarrhea, smoking, and diabetes with hazard ratios of 1.4 to 7.3. Treatment-related risk factors included prescribed dose, V43 Gy, V57 Gy (lymph node boost), and para-aortic irradiation for external beam radiation therapy (EBRT). G≥2 diarrhea at 3 years increased from 9.5% to 19.9% with prescribed dose 45 Gy versus 50 Gy, 8.7% to 14.0% with V43 Gy <2500 cm3 versus >3000 cm3 and 9.4% to 19.0% with V57 Gy <165 cm3 versus ≥165 cm3. Brachytherapy-related bowel and rectum D2cm3 were also associated with diarrhea. CONCLUSION Dose and volume effects have been established for late diarrhea after radiochemotherapy and IGABT in both CTCAE and EORTC reporting. The risk of diarrhea was lower with a pelvic EBRT prescription of 45 Gy, and higher with larger lymph node boosts volumes (ie, ≥165 cm3). The importance of EBRT volumes as determinants of late toxicity underline the need for continuous quality assurance of target contouring, dose planning, and conformity. The findings of brachytherapy dosimetric factors related to the intestines may become more important with highly conformal EBRT.
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Affiliation(s)
- Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Homi Bhabha National Institute, India
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Knoth J, Pötter R, Jürgenliemk-Schulz IM, Haie-Meder C, Fokdal L, Sturdza A, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Wiebe E, Rai B, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters BR, Sundset M, Tan LT, Nout RA, Tanderup K, Kirisits C, Nesvacil N, Lindegaard JC, Schmid MP. Clinical and imaging findings in cervical cancer and their impact on FIGO and TNM staging - An analysis from the EMBRACE study. Gynecol Oncol 2020; 159:136-141. [PMID: 32798000 DOI: 10.1016/j.ygyno.2020.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/05/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To investigate differences in local tumour staging between clinical examination and MRI and differences between FIGO 2009, FIGO 2018 and TNM in patients with primary cervical cancer undergoing definitive radio-chemotherapy. METHODS Patients from the prospective observational multi-centre study "EMBRACE" were considered for analysis. All patients had gynaecological examination and pelvic MRI before treatment. Nodal status was assessed by MRI, CT, PET-CT or lymphadenectomy. For this analysis, patients were restaged according to the FIGO 2009, FIGO 2018 and TNM staging system. The local tumour stage was evaluated for MRI and clinical examination separately. Descriptive statistics were used to compare local tumour stages and different staging systems. RESULTS Data was available from 1338 patients. For local tumour staging, differences between MRI and clinical examination were found in 364 patients (27.2%). Affected lymph nodes were detected in 52%. The two most frequent stages with FIGO 2009 are IIB (54%) and IIIB (16%), with FIGO 2018 IIIC1 (43%) and IIB (27%) and with TNM T2b N0 M0 (27%) and T2b N1 M0 (23%) in this cohort. CONCLUSIONS MRI and clinical examination resulted in a different local tumour staging in approximately one quarter of patients. Comprehensive knowledge of the differential value of clinical examination and MRI is necessary to define one final local stage, especially when a decision about treatment options is to be taken. The use of FIGO 2009, FIGO 2018 and TNM staging system leads to differences in stage distributions complicating comparability of treatment results. TNM provides the most differentiated stage allocation.
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Affiliation(s)
- J Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - R Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - C Haie-Meder
- Department of Radiotherapy, Gustave-Roussy, France
| | - L Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | - A Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - U Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, India
| | - B Segedin
- Department of Oncology, Institute of Oncology Ljubljana, Slovenia
| | - K Bruheim
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Norway
| | - E Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - B Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Cooper
- Leeds Cancer Centre, St James's University Hospital, United Kingdom
| | | | - E van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Belgium
| | - B R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - M Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - L T Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - R A Nout
- Department of Radiation Oncology, Erasmus MC, Erasmus University Rotterdam, The Netherlands
| | - K Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
| | - C Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - N Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - J C Lindegaard
- Department of Oncology, Aarhus University Hospital, Denmark
| | - M P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria.
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Tanderup K, Nesvacil N, Kirchheiner K, Serban M, Spampinato S, Jensen NBK, Schmid M, Smet S, Westerveld H, Ecker S, Mahantshetty U, Swamidas J, Chopra S, Nout R, Tan LT, Fokdal L, Sturdza A, Jürgenliemk-Schulz I, de Leeuw A, Lindegaard JC, Kirisits C, Pötter R. Evidence-Based Dose Planning Aims and Dose Prescription in Image-Guided Brachytherapy Combined With Radiochemotherapy in Locally Advanced Cervical Cancer. Semin Radiat Oncol 2020; 30:311-327. [DOI: 10.1016/j.semradonc.2020.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Smet S, Nesvacil N, Knoth J, Sturdza A, Najjari-Jamal D, Jelinek F, Kronreif G, Pötter R, Widder J, Kirisits C, Schmid MP. Hybrid TRUS/CT with optical tracking for target delineation in image-guided adaptive brachytherapy for cervical cancer. Strahlenther Onkol 2020; 196:983-992. [PMID: 32621011 PMCID: PMC7653783 DOI: 10.1007/s00066-020-01656-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/13/2020] [Indexed: 11/26/2022]
Abstract
Objective To prospectively compare the interobserver variability of combined transrectal ultrasound (TRUS)/computed tomography (CT)- vs. CT only- vs. magnetic resonance imaging (MRI) only-based contouring of the high-risk clinical target volume (CTVHR) in image-guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC). Methods Five patients with LACC (FIGO stages IIb–IVa) treated with radiochemotherapy and IGABT were included. CT, TRUS, and T2-weighted MRI images were performed after brachytherapy applicator insertion. 3D-TRUS image acquisition was performed with a customized ultrasound stepper device and software. Automatic applicator reconstruction using optical tracking was performed in the TRUS dataset and TRUS and CT images were fused with rigid image registration with the applicator as reference structure. The CTVHR (based on the GEC-ESTRO recommendations) was contoured by five investigators on the three modalities (CTVHR_CT, CTVHR_TRUS-CT, and CTVHR_MRI). A consensus reference CTVHR_MRI (MRIref) was defined for each patient. Descriptive statistics and overlap measures were calculated using RTslicer (SlicerRT Community and Percutaneous Surgery Laboratory, Queen’s University, Canada), comparing contours of every observer with one another and with the MRIref. Results The interobserver coefficient of variation was 0.18 ± 0.05 for CT, 0.10 ± 0.04 for TRUS-CT, and 0.07 ± 0.03 for MRI. Interobserver concordance in relation to the MRIref expressed by the generalized conformity index was 0.75 ± 0.04 for MRI, 0.51 ± 0.10 for TRUS-CT, and 0.48 ± 0.06 for CT. The mean CTVHR_CT volume of all observers was 71% larger than the MRIref volume, whereas the mean CTVHR_TRUS-CT volume was 15% larger. Conclusion Hybrid TRUS-CT as an imaging modality for contouring the CTVHR in IGABT for LACC is feasible and reproducible among multiple observers. TRUS-CT substantially reduces overestimation of the CTVHR volume of CT alone while maintaining similar interobserver variability.
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Affiliation(s)
- Stéphanie Smet
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Radiation Oncology, General Hospital Turnhout, Turnhout, Belgium
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Johannes Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Dina Najjari-Jamal
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Radiation Oncology, Institut Català d'Oncologia, Barcelona, Spain
| | - Filip Jelinek
- Austrian Center for Medical Innovation and Technology, Wr. Neustadt, Austria
| | - Gernot Kronreif
- Austrian Center for Medical Innovation and Technology, Wr. Neustadt, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, General Hospital of Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Sturdza A, Viswanathan AN, Erickson B, Yashar C, Bruggeman A, Feddock J, Klopp A, Beriwal S, Gaffney D, Han K, Kamrava M. American Brachytherapy Society working group report on the patterns of care and a literature review of reirradiation for gynecologic cancers. Brachytherapy 2020; 19:127-138. [PMID: 31917178 DOI: 10.1016/j.brachy.2019.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 11/22/2019] [Accepted: 11/27/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Recurrences of previously irradiated gynecological malignancies are uncommon. Standardized management of these cases is not well established. We aim to provide an in-depth literature review and present current practice patterns among an international group of experienced practitioners in the reirradiation setting of gynecologic cancers. METHODS AND MATERIALS An extensive literature search was performed and 35 articles were selected based on preset criteria. A 20-question online survey of 10 experts regarding their retreatment practices was also conducted. RESULTS The reviewed publications include a diverse group of patients, multiple treatment techniques, a range of total doses, local control, overall survival, and toxicity outcomes. Overall, local control ranged from 44% to 88% over 1-5 years with OS in the range of 39.5-82% at 2-5 years. Late G3-4 toxicity varied very broadly from 0% to 42.9%, with most papers reporting serious toxicities greater than 15%. The most common reirradiation technique utilized was brachytherapy. Some low-dose-rate data suggest improved outcomes with doses >50 Gy. The high-dose-rate data are more varied with some studies suggesting improved local control with doses >40 Gy. In general, a longer time interval between the first and second course of radiation as well as recurrences <2-4 cm tend to have improved outcomes. CONCLUSIONS Reirradiation with brachytherapy results in relatively reasonable local control and toxicities for women with recurrent gynecologic cancers. The appropriate dose for each case needs to be individualized given the heterogeneity of cases. Multidisciplinary management is critical to develop individualized plans and to clearly communicate potential side effects and expected treatment outcomes. TAKE HOME MESSAGE Reirradiation with brachytherapy is an acceptable effective organ preserving approach for recurrent gynecologic cancers with a reasonable local control and toxicity profile. Each case requires multidisciplinary management to develop an individualized approach. Monitoring for potential long-term toxicities is essential.
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Affiliation(s)
- Alina Sturdza
- Department of Radiation Oncology and Radiation Biology, Medical University of Vienna, Comprehensive Cancer Center Vienna, Austria.
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego
| | - Andrew Bruggeman
- Department of Radiation Medicine and Applied Sciences, University of California San Diego
| | | | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman cancer center
| | - David Gaffney
- Department of Radiation Oncology, University of Utah
| | - Kathy Han
- Department of Radiation Oncology, University of Toronto
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Mahantshetty U, Sturdza A, Naga CH P, Berger D, Fortin I, Motisi L, Schmid MP, Aravindakshan D, Ghadi Y, Swamidas JV, Chopra S, Gurram L, Nesvacil N, Kirisits C, Pötter R. Vienna-II ring applicator for distal parametrial/pelvic wall disease in cervical cancer brachytherapy: An experience from two institutions: Clinical feasibility and outcome. Radiother Oncol 2019; 141:123-129. [DOI: 10.1016/j.radonc.2019.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
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Bekos C, Polterauer S, Seebacher V, Bartl T, Joura E, Reinthaller A, Sturdza A, Horvat R, Schwameis R, Grimm C. Pre-operative hypoalbuminemia is associated with complication rate and overall survival in patients with vulvar cancer undergoing surgery. Arch Gynecol Obstet 2019; 300:1015-1022. [PMID: 31468203 PMCID: PMC6759670 DOI: 10.1007/s00404-019-05278-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 08/19/2019] [Indexed: 11/29/2022]
Abstract
Objective Hypoalbuminemia, a known marker for malnutrition, has been associated with an increased risk for perioperative morbidity and poor prognosis in patients with solid tumors. The aim of this study was to investigate the prognostic and predictive value of pre-treatment serum albumin levels for survival and postoperative complications in patients with vulvar cancer undergoing surgery. Methods Within in this retrospective study, we assessed data of 103 consecutive patients with vulvar cancer undergoing primary surgery into this study. Pre-treatment serum albumin levels were correlated with clinico-pathological parameters and complications. We performed univariate log-rank test and multivariable Cox regression models to evaluate the association between pre-treatment serum albumin and survival. Results We found hypoalbuminemia (< 35 mg/dl) in 9 of 103 (8.7%) patients. No difference in tumor characteristics was observed between patients with hypoalbuminemia and normal serum albumin levels. Difference in postoperative complications (55.6% and 37.8% of patients with hypoalbuminemia and normal serum albumin levels, respectively) was not statistically significant (p = 0.345). Shorter overall survival (OS) was observed in patients with hypoalbuminemia (5-year OS rate 17.1%) when compared to patients with normal serum albumin levels (5-year OS rate 58.6%, p = 0.004). In multivariable analysis, age (p = 0.017), FIGO stage (p = 0.011) and serum albumin levels (p = 0.013) were independently associated with OS. Conclusion Pre-treatment hypoalbuminemia is an independent prognostic biomarker for OS in patients with vulvar cancer. We did not find an association between pre-treatment hypoalbuminemia and a higher risk for postoperative complications. Electronic supplementary material The online version of this article (10.1007/s00404-019-05278-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christine Bekos
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stephan Polterauer
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria. .,Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria.
| | - Veronika Seebacher
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Bartl
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Elmar Joura
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Reinthaller
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.,Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Horvat
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Richard Schwameis
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christoph Grimm
- Department of Gynaecology and Obstetrics, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Tan LT, Pötter R, Sturdza A, Fokdal L, Haie-Meder C, Schmid M, Gregory D, Petric P, Jürgenliemk-Schulz I, Gillham C, Van Limbergen E, Hoskin P, Tharavichitkul E, Villafranca E, Mahantshetty U, Kirisits C, Lindegaard J, Kirchheiner K, Tanderup K. Change in Patterns of Failure After Image-Guided Brachytherapy for Cervical Cancer: Analysis From the RetroEMBRACE Study. Int J Radiat Oncol Biol Phys 2019; 104:895-902. [DOI: 10.1016/j.ijrobp.2019.03.038] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 12/14/2022]
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Knoth J, Pötter R, Jürgenliemk-Schulz I, Haie-Meder C, Fokdal L, Sturdza A, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Wiebe E, Rai B, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters B, Sundset M, Tan LT, Nout R, Tanderup K, Kirisits C, Nesvacil N, Lindegaard JC, Schmid M. Stage Migration between Clinical Examination and MRI in Locally Advanced Cervical Cancer. Brachytherapy 2019. [DOI: 10.1016/j.brachy.2019.04.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Duke S, Pötter R, Sturdza A, Schmid M, Rumpold T, Mahantshetty U, Nesvacil N, De Leeuw A, Kirisits C, Tanderup K, Nout R, Lindegaard J, Jurgenliemk-Schulz I, Tan L. OC-0176 A systematic analysis of delineation performance seen in EMBRACE-II brachytherapy quality assurance. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)30596-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Knoth J, Pötter R, Jürgenliemk-Schulz I, Haie-Meder C, Fokdal L, Sturdza A, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Wiebe E, Rai B, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Pieters B, Sundset M, Tan L, Nout R, Tanderup K, Kirisits C, Nesvacil N, Lindegaard J, Schmid M. PO-0827 Comparison of clinical examination and MRI for local cervical cancer staging (FIGO and T(NM)). Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)31247-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Fokdal L, Tanderup K, Pötter R, Sturdza A, Kirchheiner K, Chargari C, Jürgenliemk-Schulz IM, Segedin B, Tan LT, Hoskin P, Mahantshetty U, Bruheim K, Rai B, Kirisits C, Lindegaard JC. Risk Factors for Ureteral Stricture After Radiochemotherapy Including Image Guided Adaptive Brachytherapy in Cervical Cancer: Results From the EMBRACE Studies. Int J Radiat Oncol Biol Phys 2019; 103:887-894. [DOI: 10.1016/j.ijrobp.2018.11.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/10/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022]
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Seebacher V, Sturdza A, Bergmeister B, Polterauer S, Grimm C, Reinthaller A, Hilal Z, Aust S. Factors associated with post-relapse survival in patients with recurrent cervical cancer: the value of the inflammation-based Glasgow Prognostic Score. Arch Gynecol Obstet 2018; 299:1055-1062. [PMID: 30535923 PMCID: PMC6435785 DOI: 10.1007/s00404-018-4993-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 11/24/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of the present study was to assess the value of the Glasgow Prognostic Score (GPS) as a prognostic tool for predicting post-relapse survival (PRS) in patients with recurrent cervical cancer. METHODS We retrospectively evaluated the data of 116 patients with recurrent cervical cancer in whom serologic biomarkers had been assessed at the time of relapse. The GPS was calculated as follows: patients with elevated serum C-reactive protein levels and hypoalbuminemia were allocated a score of 2, and those with 1 or no abnormal value were allocated a score of 1 and 0, respectively. To assess the association between factors including the GPS and PRS, we performed uni- and multivariate survival analyzes. RESULTS After a median follow-up of 20.9 months from recurrence, a 5-year PRS rate of 25% (SE 4.7%) was observed. Only in 29.8% of the patients, recurrence was limited to the pelvis. In uni- and multivariate survival analyzes, the GPS [HR 1.6 (95% CI 0.9-2.4), p = 0.01], a history of radiation therapy as part of initial treatment [HR 2.7 (95% CI 1.1-6.9), p = 0.03], and the presence of peritoneal carcinomatosis or multiple sites of relapse [HR 4.2 (95% CI 1.9-9.3), p < 0.001] were associated with shorter PRS. The GPS correlated with higher squamous cell carcinoma antigen levels (p = 0.001), shorter median PRS (p = 0.009), and less intensive treatment for relapse (p = 0.02). CONCLUSIONS A higher GPS at the time of relapse, a history of radiation therapy, and the presence of peritoneal carcinomatosis or multiple sites of relapse are independently associated with shorter PRS in patients with recurrent cervical cancer.
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Affiliation(s)
- Veronika Seebacher
- Gynecologic Cancer Unit, Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.
| | - Alina Sturdza
- Gynecologic Cancer Unit, Department of Radiotherapy, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - Birgit Bergmeister
- Gynecologic Cancer Unit, Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - Stephan Polterauer
- Gynecologic Cancer Unit, Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - Christoph Grimm
- Gynecologic Cancer Unit, Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - Alexander Reinthaller
- Gynecologic Cancer Unit, Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - Ziad Hilal
- Department of Obstetrics and Gynecology, Ruhr-University Bochum, Bochum, Germany
| | - Stefanie Aust
- Gynecologic Cancer Unit, Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
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