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Song S, Han D, Zhang N, Mao Z, Guo X, Cheng G. The MRI-guided two adaptive brachytherapy fractions versus one adaptive brachytherapy fraction in one application for the cervical cancer: a retrospective study. Radiat Oncol 2023; 18:46. [PMID: 36879287 PMCID: PMC9990264 DOI: 10.1186/s13014-023-02237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
PURPOSE This study retrospectively compared the clinical and toxicity outcomes for the cervical cancer of the MRI-guided two adaptive brachytherapy (IGABT) fractions versus one IGABT fraction in one application. METHODS One hundred and twenty patients with cervical cancer received external beam radiotherapy combined with or without concurrent chemotherapy, which was followed by the IGABT. The IGABT in 63 patients had one IGABT in each application (Arm 1), while in the other 57 patients, at least one treatment was two continuous IGABT every other day in one application (Arm 2). Clinical outcomes including overall survival (OS), cancer specific survival (CSS), progression free survival (PFS), local control (LC) were analyzed. Brachytherapy-related toxicities were evaluated, which included pain, dizziness, nausea/vomiting, fever/infection, blood loss during the removal of applicator and needles, the deep venous thrombosis, and other acute toxicities. The Common Terminology Criteria for Adverse Events (CTC-AE 5.0) was used to evaluate the incidence and severity of toxicities of the urinary system, lower digestive system, and reproduction system. Kaplan-Meier and the Log-rank test were used to analyze the clinical outcomes. RESULTS The median follow-up time of the patients in Arm 1 and Arm 2 was 23.5 and 12.0 months, respectively. The overall treatment time was significantly shorter in Arm 2 than Arm 1 (60 vs. 64 d; P = 0.017). The OS, CSS, PFS, and LC in Arm1 and Arm 2 was 77.8% vs. 86.0% (P = 0.632), 77.8% vs. 87.7% (P = 0.821), 68.3% vs. 70.2% (P = 0.207), and 92.1% vs. 94.7% (P = 0.583), respectively. The highest NRS of the pain during brachytherapy waiting period (2.22 ± 1.84 vs. 3.02 ± 1.65; P < 0.001) and at the time of the removal of the applicator (4.69 ± 1.49 vs. 5.30 ± 1.18; P < 0.001) in the patients who received one hybrid intracavitary and interstitial brachytherapy (IC/ISBT) in one application and two continuous IC/ISBT every other day in one application were significantly different. So far four patients with grade 3 late toxicities have been reported. CONCLUSIONS The findings of this study demonstrated that the two continuous IGABT every other day in one application is a logistically applicable, safe, and effective treatment strategy that could shorten the overall treatment time and reduce the medical cost, comparing with the one IGABT in one application.
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Affiliation(s)
- Shanshan Song
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Dongmei Han
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Ning Zhang
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Zhuang Mao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Xin Guo
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, China.
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Yuk JS, Lee B, Kim K, Kim MH, Seo YS, Hwang SO, Cho YK, Kim YB. Incidence and risk of venous thromboembolism according to primary treatment type in women with endometrial cancer: a population-based study. BMC Cancer 2021; 21:1166. [PMID: 34717579 PMCID: PMC8557555 DOI: 10.1186/s12885-021-08853-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Background Current prophylaxes and treatments for venous thromboembolism (VTE) in women with gynecologic cancer are mainly guided by studies on solid cancers because studies in gynecologic cancer did not provide sufficient data. Large-scale studies evaluating the incidence and risk of VTE according to therapeutic modality may guide prophylaxis and treatment of VTE in gynecologic cancer. This study was performed to determine the incidence and risk of VTE according to primary treatment type in Korean women with endometrial cancer. Methods We selected 26,256 women newly diagnosed with endometrial cancer between 2009 and 2018 from the Korean Health Insurance Review and Assessment Service database. During the total follow-up period and first six months after primary treatments initiation, the incidence and risk of VTE were evaluated according to primary treatment type, that is, no treatment, surgery, radiotherapy, chemotherapy, or hormone therapy. Results VTE occurred in 136 per 10,000 women during the total follow-up period and in 54 per 10,000 women during the first six months with the highest frequency in women that underwent chemotherapy. During the first year, the monthly incidence of VTE decreased with time among women that underwent no treatment, surgery, or hormone therapy and remained unchanged in those that received radiotherapy or chemotherapy. Compared with women that received no treatment, VTE risk, especially of PE significantly increased in women that underwent chemotherapy (VTE: hazard ratio (HR), 2.334; 95% CI, 1.38–3.949; P = 0.002) (PE: HR, 2.742; 95% CI, 1.424–5.278; P = 0.003) or hormone therapy (VTE: HR, 2.073; 95% CI, 1.356–3.17; P = 0.001) (PE: HR, 2.086; 95% CI, 1.19–3.657; P = 0.01) during the total follow-up period and women that underwent only chemotherapy during the first six months (VTE: HR, 2.532; 95% CI, 1.291–4.966; P = 0.007) (PE: HR, 3.366; 95% CI, 1.496–7.576; P = 0.003). Conclusions In this cohort study, the incidence and risk of VTE were highest in women with endometrial cancer that underwent chemotherapy as a primary treatment. Notably, the incidence of VTE decreased over time in women that received no treatment, surgery, or hormone therapy. This study can help guide therapies for prophylaxis and treatment of VTE in women with endometrial cancer. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08853-x.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Banghyun Lee
- Department of Obstetrics and Gynecology, Inha University hospital, Inha University School of Medicine, 27, Inhang-ro, Sinheung-dong, Jung-gu, Incheon, Republic of Korea.
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Myoung Hwan Kim
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Yong-Soo Seo
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Sung Ook Hwang
- Department of Obstetrics and Gynecology, Inha University hospital, Inha University School of Medicine, 27, Inhang-ro, Sinheung-dong, Jung-gu, Incheon, Republic of Korea
| | - Yong Kyoon Cho
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea
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Yuk JS, Lee B, Kim K, Kim MH, Seo YS, Hwang SO, Yoon SH, Kim YB. Incidence and risk of venous thromboembolism according to primary treatment in women with ovarian cancer: A retrospective cohort study. PLoS One 2021; 16:e0250723. [PMID: 33909674 PMCID: PMC8081178 DOI: 10.1371/journal.pone.0250723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/12/2021] [Indexed: 12/31/2022] Open
Abstract
Objective This study aimed to investigate incidence and risk for venous thromboembolism (VTE) according to primary treatment in women with ovarian cancer. Methods We selected 26,863 women newly diagnosed with ovarian cancer between 2009 and 2018 from the Korean Health Insurance Review and Assessment Service databases. During the total follow-up period and the first six months after initiation of primary treatments, incidence and risk of VTE were evaluated according to primary treatment as no treatment, surgery, radiotherapy, or chemotherapy. Results The mean follow-up period was 1285.5±6 days. The VTE incidence was highest in women who underwent chemotherapy (306 per 10,000 women). Among women who underwent surgery, VTE was highest in surgery with neoadjuvant chemotherapy (536 per 10,000 women), followed by surgery with adjuvant chemotherapy (360 per 10,000 women) and surgery alone (132 per 10,000 women). During the first 12 months, monthly incidence of VTE decreased. Compared with women with no treatment, risk of VTE significantly increased in women undergoing chemotherapy (HR 1.297; 95% CI, 1.08–1.557; P = 0.005) during the total follow-up period and decreased in women undergoing surgery (HR 0.557; 95% CI, 0.401–0.775; P<0.001) and radiotherapy (HR 0.289; 95% CI, 0.119–0.701; P = 0.006) during the first six months. Among women who underwent surgery, VTE risk significantly increased in surgery with neoadjuvant chemotherapy (HR 4.848; 95% CI, 1.86–12.632; P = 0.001) followed by surgery with adjuvant chemotherapy (HR 2.807; 95% CI, 1.757–4.485; P<0.001) compared with surgery alone during the total follow-up period and in surgery with neoadjuvant chemotherapy (HR 4.223; 95% CI, 1.37–13.022; P = 0.012) during the first six months. Conclusions In this large Korean cohort study, incidence and risk of VTE were highest in women with ovarian cancer who underwent chemotherapy and surgery with neoadjuvant chemotherapy as a primary cancer treatment. Incidence of VTE decreased over time.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Banghyun Lee
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
- * E-mail:
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Myoung Hwan Kim
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Yong-Soo Seo
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Sung Ook Hwang
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Sang-Hee Yoon
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea
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Yuk JS, Lee B, Kim MH, Kim K, Seo YS, Hwang SO, Cho YK, Kim YB. Incidence and risk factors of VTE in patients with cervical cancer using the Korean national health insurance data. Sci Rep 2021; 11:8031. [PMID: 33850221 PMCID: PMC8044206 DOI: 10.1038/s41598-021-87606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/31/2021] [Indexed: 11/08/2022] Open
Abstract
This study investigated incidence and risk factors for venous thromboembolism (VTE) in patients with cervical cancer. We selected 49,514 patients newly diagnosed with cervical cancer from the Korean Health Insurance Review and Assessment Service databases. During the total follow-up period and first 6 months after initiation of primary treatments, incidence of VTE, and association of risk factors with VTE occurrence were evaluated according to primary treatments or no treatment, surgery, radiotherapy, and chemotherapy. VTE occurred in 1.15% of patients with cervical cancer. Regardless of the period after initiation of primary treatments, and of VTE, the incidence of thromboembolism was highest in chemotherapy. During the first 12 months, monthly incidence of VTE was highest in chemotherapy and decreased with time in all primary treatments. Compared with no treatment, VTE risk significantly increased for all primary treatments (surgery: HR 1.492; 95% CI 1.186-1.877) (radiotherapy: HR 2.275; 95% CI 1.813-2.855) (chemotherapy: HR 4.378; 95% CI 3.095-6.193) and for chemotherapy during the first 6 months (HR 3.394; 95% CI 2.062-5.588). In this cohort study, incidence and risk of VTE in patients with cervical cancer were the highest when chemotherapy was the primary cancer treatment, and incidence of VTE decreased with time.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, 1342, Dongil-ro, Nowon-gu, Seoul, Republic of Korea
| | - Banghyun Lee
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University School of Medicine, 27, Inhang-ro, Sinheung-dong, Jung-gu, Incheon, Republic of Korea.
| | - Myoung Hwan Kim
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, 1342, Dongil-ro, Nowon-gu, Seoul, Republic of Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Yong-Soo Seo
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, 1342, Dongil-ro, Nowon-gu, Seoul, Republic of Korea
| | - Sung Ook Hwang
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University School of Medicine, 27, Inhang-ro, Sinheung-dong, Jung-gu, Incheon, Republic of Korea
| | - Yong Kyoon Cho
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, 1342, Dongil-ro, Nowon-gu, Seoul, Republic of Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea
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Abstract
ObjectiveVenous thromboembolism (VTE) is a recognized complication of gynecological malignancy and represents a leading cause of morbidity and mortality in these patients. The review aimed to discuss the incidence, risk factors, and clinical presentation of VTE before examining the literature on the diagnosis, prevention, and management in the context of uterine, cervical, ovarian, and vulval cancers.Methods/MaterialsA literature search was performed using Ovid Medline and Embase with the following words: “gynecological malignancy,” “pelvic tumor,” “venous thromboembolism,” “deep vein thrombosis” and “pulmonary embolism.”ResultsThe incidence of VTE in patients with gynecological malignancy ranged between 3% and 25% and was affected by several patient and tumor factors. Duplex ultrasonography is currently the first-line imaging modality for deep venous thrombosis with sensitivity and specificity of up to 95% and 100%, respectively. Low-molecular-weight heparin is currently the VTE prophylaxis and treatment of choice for patients with gynecological malignancy, although warfarin and unfractionated heparin play a role in selected circumstances. The relatively new direct oral anticoagulants including factor Xa inhibitors and direct thrombin inhibitors are increasingly being used, although further evaluations are required, particularly in cancer patients. Catheter-directed thrombolysis and percutaneous mechanical and surgical thrombectomy may have a role in treating patients with severe symptomatic iliocaval or iliofemoral deep venous thrombosis. Overall, VTE is a poor prognosis marker in patients with gynecological malignancy.ConclusionsGynecological malignancy–associated VTE is associated with significant morbidity, contributing to a large number of life years lost. Although promising new therapies are emerging, a 2-pronged approach is required to simultaneously target cancer-specific management and predict early on those who are likely to be affected. In the meantime, clinicians should continue to combine current guidelines with a multidisciplinary team approach to ensure that these complex patients receive the best evidence-based and compassionate care.
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Thromboembolic events following brachytherapy: case reports. J Contemp Brachytherapy 2015; 7:76-8. [PMID: 25829939 PMCID: PMC4371060 DOI: 10.5114/jcb.2015.48580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/29/2014] [Accepted: 11/12/2014] [Indexed: 11/23/2022] Open
Abstract
Pulsed-dose-rate (PDR) brachytherapy is a recent brachytherapy modality combining the radiobiological advantages of low-dose-rate (LDR) brachytherapy with increased possibilities of dose optimization and radiation safety. However, treatment duration remains protracted, as the prescribed dose is typically delivered through pulses that do not exceed 0.5 Gy/h for critical organs. It is frequently used for the treatment of gynaecological malignancies. Although, the relationship between thrombosis and cancer is well known, specific data on thromboembolic events during brachytherapy are scarce. We report two cases of major thromboembolic events during brachytherapy treatment for gynaecological malignancies. We discuss the possible causal relationship between brachytherapy procedures and the occurrence of thromboembolic events, drawing a preventive practical attitude.
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Jones R, Chen Q, Best R, Libby B, Crandley EF, Showalter TN. Dosimetric feasibility of stereotactic body radiation therapy as an alternative to brachytherapy for definitive treatment of medically inoperable early stage endometrial cancer. Radiat Oncol 2014; 9:164. [PMID: 25059785 PMCID: PMC4118162 DOI: 10.1186/1748-717x-9-164] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/09/2014] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study was designed to evaluate the dosimetric feasibility of definitive stereotactic body radiation therapy (SBRT) for the treatment of medically inoperable early stage endometrial cancer. METHODS CT simulation scans from 10 medically inoperable early stage endometrial cancer patients previously treated with high dose-rate (HDR) intracavitary brachytherapy were used to generate Helical Tomotherapy (HT) plans using the IMRT mode with clinical target volumes (CTVs) that included the uterus plus cervix. A prescription dose of 34 Gy in 4 fractions was used. The SBRT dosimetry was compared to the 10 prior intracavitary brachytherapy plans normalized to a standard dose. Organs at risk (OARs) evaluated were the bladder, rectum, sigmoid, femoral heads, and other bowel, including both large and small bowel. The simulation CT and daily image guidance for 4 patients treated with this technique were evaluated to assess for interfraction variation in the uterine position and effects on dosimetry. RESULTS Compared to intracavitary brachytherapy, HT SBRT produced significantly greater overall target coverage to the uterus, boost CTV, and PTV, with exception of the V150% of the uterus. HT SBRT significantly increased dose to the rectum, bowel, and femoral heads compared to intracavitary brachytherapy, though not outside of dose tolerance limits. Review of daily image guidance for patients treated with this technique demonstrated good reproducibility with a mean overlap index of 0.87 (range, 0.74 - 0.99). CONCLUSIONS Definitive SBRT for medically inoperable early stage endometrial cancer appears to be a feasible treatment option. Future studies are warranted to evaluate long-term clinical outcomes with this technique, compared to HDR intracavitary brachytherapy.
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Affiliation(s)
| | | | | | | | | | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, 1215 Lee Street, Box 800383, Charlottesville, VA 22908, USA.
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Randomized trial of oral misoprostol treatment for cervical ripening before tandem application in cervix cancer. Int J Radiat Oncol Biol Phys 2011; 81:778-81. [PMID: 21377295 DOI: 10.1016/j.ijrobp.2010.06.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 04/18/2010] [Accepted: 06/24/2010] [Indexed: 11/22/2022]
Abstract
PURPOSE To investigate the efficacy of oral misoprostol administered to facilitate tandem application to the cervix as a part of brachytherapy in patients with cervical cancer. METHODS AND MATERIALS Eighty patients with cervical cancer who had been planned to undergo brachytherapy at Dr. Lütfi Kırdar Kartal Training and Research Hospital were evaluated in a double-blind, prospective, randomized trial. Patients were divided randomly into two groups of 40 patients. The first and second groups received 400 μg of misoprostol orally and placebo, respectively, 3 h before tandem application. The two groups were compared in terms of age, diameter of tumor, parity, age at first intercourse, amount of bleeding and pain at first tandem application, length of endometrial cavity measured by hysterometer, and size of Hegar dilators used for cervical dilatation. RESULTS Of all cases, 63.6%, 16.3%, 10%, 6.3%, 2.5%, and 1.3% were Stage IIB, IIIB, IIIA, IVA, IIA and IIC, respectively. Mean (±SD) age (range) was 49.3 ± 13.1 (25-83) years and 56.6 ± 13.2 (30-78) years in the study and control groups, respectively (p = 0.015). Age at first intercourse, diameter of tumor, parity, amount of bleeding at first tandem application, and length of endometrial cavity measured by hysterometer were not significantly different between the two groups. Pain score was significantly higher in the control group (p < 0.001). Application was significantly easier in the study group compared with controls (p < 0.001). Average size of initial Hegar dilators used for cervical dilatation was significantly higher in the study group compared with controls (p = 0.017). CONCLUSION Administration of misoprostol 400 μg orally for cervical ripening before tandem application facilitates the procedure, increases patient tolerability and comfort, and may decrease complication rates.
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Jacobson G, Lammli J, Zamba G, Hua L, Goodheart MJ. Thromboembolic events in patients with cervical carcinoma: Incidence and effect on survival. Gynecol Oncol 2009; 113:240-4. [DOI: 10.1016/j.ygyno.2009.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 01/20/2009] [Accepted: 01/27/2009] [Indexed: 12/27/2022]
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Anders JC, Grigsby PW, Singh AK. Cisplatin chemotherapy (without erythropoietin) and risk of life-threatening thromboembolic events in carcinoma of the uterine cervix: the tip of the iceberg? A review of the literature. Radiat Oncol 2006; 1:14. [PMID: 16722547 PMCID: PMC1526743 DOI: 10.1186/1748-717x-1-14] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Accepted: 05/05/2006] [Indexed: 11/10/2022] Open
Abstract
Background The risk of severe cardiovascular toxicity, specifically thromboembolic events (TE), in patients with cervical cancer receiving concurrent irradiation and cisplatin chemotherapy is reported to be less than 1% in several large prospective trials. However, the anecdotal risk appears to be far higher. Results and discussion A review of several prospective trials demonstrates no treatment related grade 4 cardiovascular toxicities and only two grade 5 toxicities in 1424 (0.1%) collective patients. A recent publication and our own unpublished experience finds 6 of 128 (4.7%) patients developed grade 4 to 5 cardiovascular (thrombosis/embolism) toxicity. The differenc in incidence of severe or life threatening cardiovascular toxicity of 0.1 versus 4.7% is highly statistically significant (p < 0.00001.) Conclusion This dramatic difference in incidence of cardiovascular toxicity raises the possibility that cardiovascular toxicities were inadequately reported on the listed prospective trials. For those patients enrolled in prospective trials, we suggest that thromboses should be diligently documented and reported. Only after the true incidence of thromboses is established can we implement appropriate levels of early screening and intervention that may prevent life threatening complications.
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Affiliation(s)
- Jon C Anders
- Radiation Oncology Associates, Albuquerque NM 87109, USA
| | - Perry W Grigsby
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis MO 63110, USA
| | - Anurag K Singh
- National Cancer Institute, Radiation Oncology Branch, Bethesda MD 20892, USA
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Wang X, Fu S, Freedman RS, Kavanagh JJ. Venous thromboembolism syndrome in gynecological cancer. Int J Gynecol Cancer 2006; 16 Suppl 1:458-71. [PMID: 16515646 DOI: 10.1111/j.1525-1438.2006.00515.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) could be presented as an initial clinical feature in some cancer patients or a complication followed by various cancer treatments, which all indicates a poor outcome. This review focuses on elucidating the relationship of VTE and the main gynecological cancers including ovarian, endometrial, and cervical cancers. First, the general VTE information about gynecological cancer are introduced; second, the risk factors of VTE developing in gynecological cancer were discussed; third, we do a retrospective analysis on a novel treatment targeting coagulation cascade; and last, we analyze VTE as a remarkable complication followed by recombinant human erythropoietin and anti-vascular endothelial growth factor treatment in gynecological cancer patients. In summary, the interaction between the coagulation system and cancer progression is a novel promising area to be explored in the study of VTE in patients with gynecological cancer.
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Affiliation(s)
- X Wang
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Second Medical University, Shanghai, China
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Jacobson GM, Kamath RS, Smith BJ, Goodheart MJ. Thromboembolic events in patients treated with definitive chemotherapy and radiation therapy for invasive cervical cancer. Gynecol Oncol 2005; 96:470-4. [PMID: 15661237 DOI: 10.1016/j.ygyno.2004.10.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Determine the incidence of and risk factors for thromboembolic events (TE) in patients treated with definitive chemoradiation for cervical cancer at our institution. METHODS A retrospective chart review was performed of all patients with a diagnosis of invasive carcinoma of the cervix (FIGO Stage IB-IVA) treated with definitive chemoradiation at University of Iowa Hospitals and Clinics (UIHC) from July 2002 to December 2003. Forty-eight patients met these criteria. All but one patient received 45 Gy to the pelvis followed by brachytherapy, IMRT, or conformal boost. One patient received 39.6 Gy to the pelvis. Cisplatin chemotherapy, 40 mg/m squared, was given weekly for 6 weeks. Data were collected for FIGO stage, age, body mass index (BMI), and smoking history. TE were confirmed by Doppler ultrasound or pulmonary imaging. Log-rank tests were used to examine the association between time to TE and the variables FIGO stage and smoking status. The association between time to TE and the continuous variables age and BMI was examined with Cox proportional hazards regression. All tests were two-sided and carried out to the 5% level of significance using the SAS statistical software package. RESULTS Minimum follow-up was 8 months. Eight patients (16.7%) developed a TE. The associations were not statistically significant for stage (P = 0.72), smoking status (P = 0.72), age (P = 0.63) or BMI (P = 0.86). Risk factors were similar in both groups. Data review suggests that the entire group had risk factors for TE. CONCLUSIONS We noted a high incidence of TE (16.7%) in patients treated at UIHC with chemoradiation for invasive cervical cancer. We did not find a statistical association between age, stage, smoking history, or BMI and risk of TE in this group. Patients with and without TE had multiple risk factors for TE.
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Affiliation(s)
- Geraldine M Jacobson
- Gynecological Oncology, Department of Radiation Oncology, University of Iowa Hospitals and Clinics, W 189Z General Hospital, 200 Hawkins Drive, Iowa City IA 52242, USA.
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Mundt AJ, Roeske JC. Can intensity-modulated radiation therapy replace brachytherapy in the management of cervical cancer? Counterpoint. Brachytherapy 2004; 1:192-4. [PMID: 15062166 DOI: 10.1016/s1538-4721(03)00002-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Arno J Mundt
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
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Sahinler I, Cepni I, Oksuz DC, Cepni K, Koksal S, Koca A, Atkovar G, Okkan S. Tandem application with transvaginal ultrasound guidance. Int J Radiat Oncol Biol Phys 2004; 59:190-6. [PMID: 15093916 DOI: 10.1016/j.ijrobp.2003.10.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2003] [Revised: 09/08/2003] [Accepted: 10/15/2003] [Indexed: 12/01/2022]
Abstract
PURPOSE Intrauterine tandem placement can be difficult in brachytherapy for cervical cancer. A prospective study was planned to investigate transvaginal ultrasound (TVU) guidance for intrauterine tandem insertions in the treatment of cervix cancer. METHODS AND MATERIALS Between January 1997 and January 2002, TVU was used after pelvic external beam radiotherapy in 48 cervical cancer patients with a high complication risk because the cervical canal orifice could not be identified and/or the patients could not undergo hysterometry. The TVU findings were graded as 1-4, with a higher number indicating greater difficulty in implantation. The tandem was inserted using the guidance of the TVU findings. Tandem application difficulties were graded in accordance with the number of implantation trials. The relations between tandem applicability and possible factors were analyzed. RESULTS By TVU, the difficulties in tandem insertion were graded as Grade 1 in 5 cases, Grade 2 in 23 cases, Grade 3 in 17 cases, and Grade 4 in 3 cases. The tandem was inserted in 19 patients on the first try, 12 patients on the second try, 12 patients on the third try, and 2 patients on the fourth try. However, the cervical canal could not be opened in 3 patients. Factors such as median age, stage, chemotherapy, diameter of the tandem applicators, time between external beam radiotherapy and brachytherapy, and the rate of tumor regression were not statistically significant. The ultrasound grade (p = 0.02) and diameter of the tandem applicator (p = 0.007) were statistically significant. Perforation and sepsis were not observed. CONCLUSION TVU guidance before brachytherapy has a positive contributory effect in reducing the morbidity rate of patients considered high risk.
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Affiliation(s)
- Ismet Sahinler
- Department of Radiation Oncology, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey.
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Kushner DM, Fleming PA, Kennedy AW, Wilkinson DA, Lee E, Saffle PA. High dose rate192Ir afterloading brachytherapy for cancer of the vagina. Br J Radiol 2003; 76:719-25. [PMID: 14512332 DOI: 10.1259/bjr/15634046] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report results of brachytherapy for carcinoma of the vagina, utilizing a Nucletron high dose rate system for Delclos Vaginal Applicators (cylinder) and Syed Template Applicators (interstitial). The linear quadratic (LQ) model was used to determine the optimum time-dose-fractionation schedules. Interstitial doses were determined at the isodose line that included gross tumour. Cylinder doses were determined either at the vaginal surface (5 cases), at 0.5 cm depth (5 cases), or at 1.0 cm depth (1 case). For the first treatment (n=19), interstitial templates were utilized in 8 patients and vaginal cylinders in 11. 11 patients received second treatments: 6 templates and 5 cylinders. The median dose of external beam radiation (n=15) was 40.0 Gy followed, after a median 23 day interval, by high dose rate brachytherapy (HDRB) of 4 fractions in 30-42 h; then a median interval gap of 25 days, followed by repeat HDRB. The median total fractionated HDRB dose per patient was 23.0 Gy (range: 6.9 Gy to 40.4 Gy; calculated low dose rate equivalent of 29.8 Gy). Tumour histologies included 14 squamous cell carcinomas, 2 adenocarcinomas, 2 melanomas, and 1 small cell tumour. Three patients experienced early brachytherapy-related complications (diarrhoea, dysuria and labial dermatitis). Three patients (15.8%) developed serious/late complications including ureteral stenosis, painful vaginal necrosis and small bowel obstruction. The first of these patients received 2 templates, the second a cylinder followed by a template and a cylinder, and the third a single cylinder. The 2 year progression-free survival was 39.3% (median 15.7 months), while the 2 year overall survival was 66.1% (median 29.9 months). (192)Ir afterloading HDRB is a feasible approach to women with vaginal cancer with acceptable toxicity and tumour response. Potential advantages include patient preference, outpatient cost-effectiveness in the case of cylinder technique, and no radiation exposure to hospital personnel. Long-term follow-up is needed to further assess late complications, and larger studies are needed to confirm our results.
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Affiliation(s)
- D M Kushner
- Department of Obstertrics and Gynecology, University of Wisconsin Hospital and Clinics, H4/636 CSC, 600 Highland Avenue, Madison, WI 53792-3236, USA
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Chadha M. Gynecologic brachytherapy-II: Intravaginal brachytherapy for carcinoma of the endometrium. Semin Radiat Oncol 2002; 12:53-61. [PMID: 11813151 DOI: 10.1053/srao.2002.28665] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Brachytherapy plays a significant role in the management of endometrial cancer. In the adjuvant setting, based on pathologic risk factors, intravaginal brachytherapy alone, external radiation therapy alone, or a combination of the two is recommended. For patients who are medically inoperable, brachytherapy with or without external beam therapy is the mainstay of treatment. In recurrent disease, to achieve improved local regional control interstitial and/or intravaginal brachytherapy is used as a boost. This article will highlight the indications and technical aspects of postoperative intravaginal brachytherapy, which is the most common application of brachytherapy in endometrial cancer.
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Affiliation(s)
- Manjeet Chadha
- Department of Radiation Oncology, Beth Israel Medical Center, New York, NY 10003, USA
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Rotmensch J, Connell PP, Yamada D, Waggoner SE, Mundt AJ. One versus two intracavitary brachytherapy applications in early-stage cervical cancer patients undergoing definitive radiation therapy. Gynecol Oncol 2000; 78:32-8. [PMID: 10873406 DOI: 10.1006/gyno.2000.5822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to compare the outcomes of early stage cervical cancer patients undergoing definitive radiation therapy (RT) with one versus two low-dose-rate intracavitary brachytherapy (ICB) applications. METHODS AND MATERIALS Between 1983 and 1993, 140 stage IB-IIA patients underwent whole-pelvis RT (WPRT) and ICB. Prior to 1988, 56 patients (40%) received two ICB applications. After 1988, our policy was modified and subsequently 84 (60%) patients underwent one application. Patient, tumor, and treatment characteristics, outcome, and complications of the two groups were compared. RESULTS The groups were balanced in terms of race, hemoglobin level, histology, grade, treatment duration, chemotherapy, and follow-up. The single-application group, however, had more stage IB disease, had small (< or =4 cm) tumors, and received higher WPRT and lower point A doses. Overall, the two groups had similar 5-year local control (P = 0.83) and disease-free (P = 0.23) and cause-specific (P = 0.29) survival rates. Moreover, no differences were seen when analyzed by tumor size or stage. On multivariate analysis, the number of applications was not correlated with recurrence (P = 0.59, hazard rate = 1.1, 95% confidence interval = 0.6-2.2). Chronic complications were similar in the two groups. CONCLUSION Our nonselected comparison of one versus two ICB applications in early-stage cervical cancer patients reveals comparable outcomes and complication rates for the two approaches. These results support the use of a single application in early-stage patients undergoing definitive RT.
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Affiliation(s)
- J Rotmensch
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, IL 60637, USA.
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18
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Jhingran A, Eifel PJ. Perioperative and postoperative complications of intracavitary radiation for FIGO stage I-III carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2000; 46:1177-83. [PMID: 10725629 DOI: 10.1016/s0360-3016(99)00545-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE To evaluate perioperative and postoperative complications of low-dose-rate (LDR) intracavitary radiation therapy in patients with FIGO Stage I-III carcinoma of the uterine cervix. METHODS AND MATERIALS We retrospectively reviewed the medical and radiotherapy records of all patients treated with radiation between 1960 and 1992 at The University of Texas M. D. Anderson Cancer Center for FIGO I-III carcinomas of the cervix. Patients who had had initial hysterectomy or whose treatment did not include intracavitary irradiation were excluded. The final study included 4043 patients who had undergone 7662 intracavitary procedures. RESULTS Eleven (0. 3%) patients had documented or suspected cases of thromboembolism resulting in 4 deaths. Of these 11 patients, 8 had clinical or radiographic evidence of tumor involving pelvic nodes or fixed pelvic wall. The risk of postoperative thromboembolism did not decrease significantly with the routine use of mini-dose heparin prophylaxis (p = 0.3). Other life-threatening perioperative complications included myocardial infarction (1 death in 5 patients), cerebrovascular accident (2 patients), congestive heart failure or atrial fibrillation (3 patients), and halothane liver toxicity (2 deaths in 2 patients). Intraoperative complications included uterine perforation (2.8%) and vaginal laceration (0.3%), which occurred more frequently in patients >/= 60 years old (p < 0.01). Fourteen percent of patients had a temperature >/= 101 degrees F during at least one hospital stay. The only correlation between minor intraoperative complications and disease-specific survival was found in patients who had Stage III disease and uterine perforation; survival was significantly (p = 0.01) decreased in these patients. CONCLUSIONS Fatal or life-threatening complications of intracavitary treatment were very rare. Deep venous thrombosis (DVT) and pulmonary embolism (PE) did not occur in otherwise healthy patients with early disease and were rare even when disease was more advanced. Minor perioperative complications were not correlated with serious late complications or with death from disease.
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Affiliation(s)
- A Jhingran
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Wollschlaeger K, Connell PP, Waggoner S, Rotmensch J, Mundt AJ. Acute problems during low-dose-rate intracavitary brachytherapy for cervical carcinoma. Gynecol Oncol 2000; 76:67-72. [PMID: 10620444 DOI: 10.1006/gyno.1999.5627] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To estimate the incidence and severity of problems arising during the hospitalization of cervical carcinoma patients undergoing low-dose-rate intracavitary brachytherapy (ICB). METHODS One hundred seventy ICB implants in 128 cervical carcinoma patients undergoing curative radiation therapy were reviewed. All events during the hospitalization requiring physician evaluation and/or intervention were scored as a "problem" and divided into 10 categories (fever/infection, pain, gastrointestinal, renal, pulmonary, cardiac, dermatologic, gynecologic, endocrinologic, psychiatric). Problems were scored as mild (no significant morbidity, therapy not discontinued), moderate (therapy discontinued but no significant morbidity), or severe (significant morbidity or mortality). Patient and treatment factors were correlated with acute problems. RESULTS Forty-two implants (24.7%) were associated with acute problems (95% minor, 5% moderate, 0% severe). The most common types were fever/infection (14.1%) and gastrointestinal problems (5. 9%). Other problem types occurred in <3% of implants. No patient or treatment factor including age, comorbid disease, weight, implant duration, or anesthesia type was significantly correlated with acute problems. Patients who developed acute problems had a survival (P = 0.21) and risk of late sequelae (P = 0.74) similar to those of patients without acute problems. CONCLUSION Problems occur during the hospitalization in approximately one-quarter of cervical carcinoma patients undergoing low-dose-rate ICB. However, most are minor and do not result in morbidity, require discontinuation of therapy, or adversely impact on outcome.
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Affiliation(s)
- K Wollschlaeger
- Section of Gynecologic Oncology, University of Chicago Hospitals, Chicago, Illinois, 60637, USA
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Petereit DG, Tannehill SP, Grosen EA, Hartenbach EM, Schink JC. Outpatient vaginal cuff brachytherapy for endometrial cancer. Int J Gynecol Cancer 1999; 9:456-462. [PMID: 11240811 DOI: 10.1046/j.1525-1438.1999.99061.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Petereit DG, Tannehill SP, Grosen EA, Hartenbach EM, Schink JC. Outpatient vaginal cuff brachytherapy for endometrial cancer. The objective of this study was to determine the efficacy and complications of postoperative high-dose-rate (HDR) vaginal-cuff brachytherapy (VCB) in patients with endometrial carcinoma. Between August 1989 to September 1997, 191 patients were treated postoperatively after a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO) with outpatient adjuvant HDR VCB for low-risk endometrial cancer (IB-84%, grade 1 or 2-96%). Patients were treated with 2 HDR fractions, delivered one week apart while under conscious sedation (16.2 Gy X 2 to the vaginal surface). All clinical endpoints were calculated using the Kaplan Meier method. The median time in the brachytherapy suite was 60 min in which no acute complications were observed. The 30-day morbidity and mortality rates were both 0%. With a median follow-up of 38 months (12-82 months), the 4-year survival, relapse-free survival, and vaginal-control rates were 95%, 98%, and 100%, respectively. One patient developed a colo-vaginal fistula at 5 years. Adjuvant HDR VCB in 2 outpatient insertions produced 100% vaginal control rates with minimal morbidity. The advantages of high dose-rate compared to low dose-rate vaginal brachytherapy include patient convenience, markedly shorter treatment times (1 h per insertion), and reduction in the cost and potential morbidity of hospitalization. HDR brachytherapy approach is a cost-effective alternative to either low-dose-rate brachytherapy or whole pelvic radiotherapy in carefully selected patients.
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Affiliation(s)
- D. G. Petereit
- Departments of Radiation Oncology and Gynecologic Oncology, University of Wisconsin Medical School, Madison, Wisconsin, USA
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21
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Nag S, Orton C, Young D, Erickson B. The American brachytherapy society survey of brachytherapy practice for carcinoma of the cervix in the United States. Gynecol Oncol 1999; 73:111-8. [PMID: 10094890 DOI: 10.1006/gyno.1998.5334] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to survey the brachytherapy practice for cervical cancer in the United States. METHODS The Clinical Research Committee of the American Brachytherapy Society (ABS) performed a retrospective survey of individual physicians of the ABS and American Society of Therapeutic Radiologists and Oncologists regarding the details of the brachytherapy techniques they personally used in the treatment of cervical cancer patients for the year 1995. The replies (some of which may have been an estimate only) were tabulated. The scope of this survey did not allow us to verify the data by chart audits. RESULTS A total of about 3500 questionnaires were mailed out; 521 responses were received. Of these responders, 206 (40%) did not perform any brachytherapy for carcinoma of the cervix in 1995. Of the other 315 responders reporting a total of 4892 patients treated in 1995, 88% used low dose rate (LDR) while 24% used high dose rate (HDR). There was a wide variation in the doses used. For LDR treatments, the median total external beam radiation therapy (EBRT) dose was 45 and 50 Gy and the LDR dose was 42 and 45 Gy for early and advanced cancers, respectively. For HDR treatments, the median EBRT dose was 48 and 50 Gy and the median HDR dose was 29 and 30 Gy for early and advanced cancers, respectively. The median dose per fraction was 6 Gy for a median of five fractions. Interstitial brachytherapy was used as a component of the treatment in 6% of the patients by 21% of responders. Very few responders treated with pulsed or medium dose rates. CONCLUSION This retrospective survey showed the current brachytherapy practice pattern in the treatment of cervical cancer in the United States and can serve as a basis for future prospective national brachytherapy data registry. There was wide variation in the practice pattern, emphasizing the urgent need for consensus on these issues.
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Affiliation(s)
- S Nag
- The Ohio State University, Columbus, Ohio, 43210, USA.
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22
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Petereit DG, Sarkaria JN, Chappell RJ. Perioperative morbidity and mortality of high-dose-rate gynecologic brachytherapy. Int J Radiat Oncol Biol Phys 1998; 42:1025-31. [PMID: 9869225 DOI: 10.1016/s0360-3016(98)00349-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine the 30-day morbidity and mortality rates for patients with an intact uterus undergoing high-dose-rate (HDR) brachytherapy, and to assess risk factors which may predict for these potentially life-threatening complications. METHODS AND MATERIALS From August 1989 to December 1994, 128 cervical and 41 medically inoperable endometrial cancer patients were treated with 5 outpatient weekly HDR brachytherapy insertions. Patients with cervical cancer also were treated with external beam radiotherapy. Acute events that resulted in either hospitalization (morbidity) or death (mortality) within 30 days of the implant were analyzed. Univariate and multivariate analyses were performed to identify risk factors. RESULTS Overall there were 16 acute events in 169 patients (9.5%). The overall morbidity and mortality rates for the cervical and endometrial patients were 5.5%, 1.6%, 7.3%, and 9.8%, respectively. The following factors were significant by univariate analysis: age per decade, American Society of Anesthesiologists (ASA) score, Karnofsky Performance Status (KPS), significant medical history, diagnosis of cervical vs. endometrial cancer, and mean time exceeding 160 minutes for the procedure. Since age was the most significant predictive factor (p = 0.0003), bivariate analyses were performed by adjusting for age. In these analyses only ASA and KPS maintained significance, while a positive medical history was of borderline significance (p = 0.07). CONCLUSION The morbidity and mortality rates observed in gynecologic patients selected for HDR brachytherapy were similar to low-dose-rate, but higher than other HDR reports. Reasons for this include a higher risk population, especially those with medically inoperable endometrial cancer. In the cervical cancer patients, some of the complications may have also been a result of the external beam portion of the radiation. In order to minimize the acute complications observed in the present HDR brachytherapy system, the following changes have been implemented: appropriate patient selection, anesthesiology involvement to monitor conscious sedation for high-risk patients, external beam radiotherapy alone in patients at extremely high risk, deep vein thrombosis (DVT) prophylaxis, use of intraoperative ultrasound, shorter duration in the brachytherapy suite, and preradiation treatment plans (plans executed prior to the insertion) if applicable. Finally, this analysis suggests that these procedures should be performed in a hospital-based setting where appropriate support is available.
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Affiliation(s)
- D G Petereit
- Department of Radiation Oncology, University of Wisconsin Medical School, Madison 53792-0600, USA
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Charra-Brunaud C, Peiffert D, Hoffstetter S, Luporsi E, Guillemin F, Bey P. [Low-dose postoperative vaginal brachytherapy of adenocarcinoma of the endometrium]. Cancer Radiother 1998; 2:34-41. [PMID: 9749094 DOI: 10.1016/s1278-3218(98)89059-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Surgery is the primary treatment for endometrial carcinoma. Methods of complementary treatment are still debated, with the potential association of external radiotherapy and/or brachytherapy before or after surgery. This study was aimed at evaluating local control and complications rates in a series of patients treated by hysterectomy followed by postoperative vaginal low-dose rate brachytherapy (BT) combined with pelvic irradiation in case of poor prognosis factors. PATIENTS AND METHODS From 1978 to 1993, 101 patients were treated at the Centre Alexis-Vautrin, France according to this scheme. Forty five had deep myometrial invasion, and thirteen cervical involvement. Fifty patients received pelvic irradiation (median dose 46 Gy) combined with BT (dose 14 Gy, median volume 127 cm3); 51 patients had BT alone (dose 60 Gy, median volume 71 cm3). RESULTS The 5-year overall survival rate was 83% and the local control rate 97% with a median follow-up of 7 years. Multivariate analysis showed two factors of bad prognosis, i.e., deep myometrial invasion and cervical involvement. Three severe complications occurred in two patients for whom the treated volume was larger than the theoretical target volume. Eleven patients developed metastases. CONCLUSION Results obtained from this series are comparable with those of previous studies, particularly in regard to pre-operative BT. The complication rate is also satisfactory and depends on the irradiation precision and the definition of the target volume.
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Affiliation(s)
- C Charra-Brunaud
- Service de curiethérapie, centre Alexis-Vautrin, Vandaeuvre-lès-Nancy, France
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Abstract
Modern intracavitary brachytherapy carefully combined with megavoltage external beam radiotherapy is responsible for the high cure rates achieved with radiation treatment of invasive cervical cancers. Pelvic disease recurrence is rare after treatment of patients with tumors < 5 cm in diameter, and even patients with massive tumors 8-10 cm in diameter are cured in 30-50% of cases. Inoperable adenocarcinomas of the endometrium and superficial cancers of the vagina are also effectively treated with intracavitary irradiation. The relative radioresistance of the uterus and vagina, physical advantages resulting from exploitation of the inverse square law, and the radiobiological advantages of low dose rate radiation have combined to make intracavitary irradiation a critical tool in the management of many gynecologic neoplasms.
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Affiliation(s)
- P J Eifel
- Department of Radiation Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, USA
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25
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Leborgne F, Fowler JF, Leborgne JH, Zubizarreta E, Chappell R. Fractionation in medium dose rate brachytherapy of cancer of the cervix. Int J Radiat Oncol Biol Phys 1996; 35:907-14. [PMID: 8751399 DOI: 10.1016/0360-3016(96)00184-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To establish an optimum fractionation for medium dose rate (MDR) brachytherapy from retrospective data of patients treated with different MDR schedules in comparison with a low dose rate (LDR) schedule. METHODS AND MATERIALS The study population consists of consecutive Stage IB-IIA-IIB patients who received radiotherapy alone with full dose brachytherapy plus external beam pelvic and parametrial irradiation from 1986-1993. Patients also receiving surgery or chemotherapy were excluded. The LDR group (n = 102, median follow-up: 80 months) received a median dose to Point A of two 32.5 Gy fractions at 0.44 Gy/h plus 18 Gy of external whole pelvic irradiation. The MDR1 group (n = 30, median follow-up: 45 months) received a mean dose of two 32 Gy fractions at 1.68 Gy/h. An individual dose reduction of 12.5% was planned for this group according to the Manchester experience, but only a 4.8% dose reduction was achieved. The MDR2 group (n = 10, median follow-up: 36 months) received a dose of two 24 Gy fractions at 1.65 Gy/h. The MDR3 group (n = 10, median follow-up 33 months) received a mean dose of three 15.3 Gy fractions at 1.64 Gy/h. And finally, the MDR4 group (n = 38, median follow-up: 24 months) received six 7.7 Gy fractions from two pulses 6 h apart in each of three insertions at 1.61 Gy/h. The median external pelvic dose to MDR schedules was between 12 and 20 Gy. The linear quadratic (LQ) formula was used to calculate the biologically effective dose (BED) to tumor (Gy10) and rectum (Gy3), assuming T1/2 for repair = 1.5 h. RESULTS The crude central recurrence rate was 6% for LDR (mean BED = 95.4 Gy10) and 10% for MDR4 (mean BED = 77.0 Gy10) (p = NS). The remaining MDR groups had no recurrences. Grade 2 and 3 rectal or bladder complications were 0% for LDR (rectal BED = 109 Gy3) 83% for MDR1 (BED = 206 Gy3), and 30% for MDR3 (BED = 127 Gy3). The MDR2 and MDR4 groups presented no complications (BED, 123 Gy3, and 105 Gy3, respectively). The LQ formula appears to correlate with late complications of the different MDR regimens. A BED above 125 Gy3 was associated with Grade 2 + 3 rectal complications. Adequate central tumor control may be compromised with a tumor BED below 90-95 Gy10. CONCLUSIONS Medium dose rate brachytherapy at 1.6 Gy/h to Point A has a marked dose rate effect. Increased fractionation is the cost of overcoming the less favorable therapeutic ratio for MDR than for LDR. A larger (25%) reduction of brachytherapy dose than previously reported is also necessary. Our most recently developed schedule for Stage I-II patients is three insertions on three treatment days with six 8.0 Gy brachytherapy fractionations, two on each treatment day, following or preceding an external whole pelvis dose of 18 Gy, and followed by additional external parametrial dose.
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Affiliation(s)
- F Leborgne
- Department of Radiation Oncology, Hospital Italiano, Montevideo, Uruguay
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Abitbol AA, Wolfson AH, Lewin AA, Houdek PV, Laufer KA, Brandon AH, Ting JY, Raub WA, Averette HE, Sevin BU, Markoe AM. Management of stage I-B, II-A, and II-B carcinoma of the cervix with high-dose-rate brachytherapy: initial results of an institutional clinical trial. Am J Clin Oncol 1996; 19:223-8. [PMID: 8638529 DOI: 10.1097/00000421-199606000-00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In 1989, the University of Miami began a program incorporating high-dose-rate (HDR) brachytherapy into the definitive treatment of patients with invasive carcinoma of the cervix. Patients received an average total dose to point A of 5,511 cGy (range 4,280-6,360 cGy) in an average of 57 days (range 39-84 days). An analysis of the first 24 cases found 11 FIGO Stage I-B, four Stage II-A, and nine Stage II-B tumors. At the end of all radiation therapy, 19/24 patients' tumors (79.2%) had undergone a clinical complete response (CR). With median follow-up of 26 months (range 14-63 months), three have relapsed locally, two regionally, and six in extrapelvic sites. Almost two-thirds of all failures occurred in patients with tumors >4 cm, who also took more than 8 weeks to complete their treatment. Overall 2-year actuarial survival for the entire study group is approximately 74%. A univariate analysis determined that clinical stage (P = 0.02), overall treatment time (P = 0.03), tumor size (P = 0.05), and response at the end of therapy (P = 0.005) were significant prognostic factors. Multivariate analysis showed that tumor response to therapy was the most important prognosticator of outcome (P = 0.001). Besides five cases of apical vaginal stenosis, there have been no reported chronic complications in this cohort of patients. A prospectively randomized trial is recommended to compare the efficacy of HDR vs. low-dose-rate brachytherapy in cervical carcinoma.
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Affiliation(s)
- A A Abitbol
- Department of Radiation Oncology, Baptist Hospital of Miami, FL 33176, USA
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Grigsby PW, Slessinger ED, Teague SP, Williamson JF, Perez CA. Clinical evaluation of an interstitial remote afterloading device for multichannel intracavitary irradiation. Int J Radiat Oncol Biol Phys 1995; 31:875-81. [PMID: 7860401 DOI: 10.1016/0360-3016(94)00539-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of this report is to describe the clinical implementation and evaluation of an interstitial remote afterloading device for multichannel intracavitary brachytherapy. METHODS AND MATERIALS Two 15-channel low dose rate devices were adapted for use with Fletcher-Suit tandem and ovoids and Simon-Heyman capsules. The technical records for 103 intracavitary brachytherapy procedures performed from February 1989 through February 1991 were reviewed. RESULTS Isodose distributions from fixed source trains for Microselectron low dose rate gynecologic applicators closely approximate standard manual afterloading sources and applicators. Device malfunctions occurred in 51% (53 out of 103) of the procedures. Malfunctions by applicator type were 70% (51 out of 73) for tandem, ovoids, and capsules, 12% (2 out of 17) for tandem and ovoids, and none (0 out of 13) for ovoids only. The most common malfunction occurred during source transfer. Total implant time was prolonged 0 to 4% by malfunction and 10% by patient care interruptions, depending on applicator type. CONCLUSION The adaptation of the Microselectron device for multichannel gynecologic intracavitary brachytherapy results in similar dose distributions as standard manual after loading sources and a decreased radiation exposure to nursing personnel. The system has a high rate of malfunctions but a low overall prolongation of implant time due to malfunction.
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Affiliation(s)
- P W Grigsby
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110
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Chao CK, Grigsby PW, Perez CA, Camel HM, Kao MS, Galakatos AE, Boyle WA. Brachytherapy-related complications for medically inoperable stage I endometrial carcinoma. Int J Radiat Oncol Biol Phys 1995; 31:37-42. [PMID: 7995766 DOI: 10.1016/0360-3016(94)00399-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE The current study was conducted to investigate the incidence and risk factors for medical complications associated with low dose rate brachytherapy in patients with medically inoperable Stage I endometrial cancer treated with irradiation alone. METHODS AND MATERIALS From 1965 through 1991 at Mallinckrodt Institute of Radiology, 150 implants were performed on 96 patients who were deemed medically unfit for hysterectomy because of advanced age, obesity, and various medical problems. The records of these patients were examined retrospectively to determine the incidence of medical complications that occurred in the first 30 days following the initiation of brachytherapy. The association of risk factors that precluded major surgery and the occurrence of brachytherapy-related complications was examined by logistic regression. RESULTS Of these 96 patients, 40 patients were older than 75 years, and 31 patients were deemed morbidly obese. Medical problems included hypertension in 45 patients, and diabetes in 37; there was a history of congestive heart failure in 23, stroke in 11, myocardial infarction in 10, and thromboembolism in 8. There were concurrent malignancies in five patients. Implants were performed using intrauterine Simon-Heyman capsules, tandems, and vaginal ovoids in all patients. General anesthesia was used for 98 implants, spinal anesthesia for 26, local anesthesia for 25, and epidural anesthesia for 1. The duration of anesthesia ranged from 30 to 120 min (median, 60 min). The duration of radioisotope application ranged from 11 to 96 h (median, 46 h). Preventive measures included low dose subcutaneous heparin in 55 patients (since 1978), and intermittent pneumatic compression boots in 29 (since 1985). Four patients developed life-threatening complications including myocardial infarction (two patients), congestive heart failure (one patient), and pulmonary embolism (one patient). Two of these four patients died; one with a myocardial infarction and the other with pulmonary embolism. The morbidity rate was thus 4.2% (4 out of 96), and the mortality was 2.1% (2 out of 96). Although the four serious complications occurred within 30 days of the procedure, only one complication and one death occurred during treatment. There was no correlation between occurrence of complications and medical risk factors, type and duration of anesthesia, or type and duration of implant. CONCLUSIONS There is a low incidence of complications associated with conventional low dose rate brachytherapy. The procedure is well tolerated in patients with medically inoperable Stage I endometrial cancer. In comparison to the predicted serious complication rate of surgery in these patients, the number of life-threatening complications from brachytherapy appears to be quite acceptable.
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Affiliation(s)
- C K Chao
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, St. Louis, MO
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Lanciano R, Corn B, Martin E, Schultheiss T, Hogan WM, Rosenblum N. Perioperative morbidity of intracavitary gynecologic brachytherapy. Int J Radiat Oncol Biol Phys 1994; 29:969-74. [PMID: 8083098 DOI: 10.1016/0360-3016(94)90390-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To define the incidence and severity of perioperative morbidity and its subsequent management with standard tandem and ovoid insertions and to evaluate pretreatment and treatment factors associated with an increased risk of perioperative morbidity. METHODS AND MATERIALS Ninety-five tandem and ovoid insertions were performed at the Fox Chase Cancer Center between 1985 and 1992 for cervical (n = 91) and endometrial (n = 4) cancer. Patients were placed on antibiotics in 19%, usually for a positive routine preoperative urine culture, but no patient was given prophylactic antibiotic therapy. Deep-vein thrombosis prophylaxis was practiced for 70% of implants and included subcutaneous heparin (40%), graduated compression elastic stockings (16%), and external pneumatic calf compression (14%). All patients were placed on prophylactic diphenoxylate hydrochloride, with doses ranging from three to eight tablets/day. RESULTS Intraoperative complications were seen in 3% of implants and included two perforations and a vaginal laceration in two patients. Twenty-four percent of implants (16 patients) developed temperatures of > 100.5 (range 100.6 to 103), although only one patient required implant removal because of fever. Management of fever included antibiotics in 35% and acetaminophen only in 65%. Five implants (5%) were removed emergently secondary to presumed sepsis (n = 1), exacerbation of chronic obstructive pulmonary disease, hypotension, change in mental status (n = 3), and myocardial infarction/congestive heart failure (n = 1). No patient developed a deep-vein thrombosis, pulmonary embolism, gastrointestinal obstruction, or died of a postoperative complication. Univariate analysis of pretreatment and treatment factors revealed older age (p < 0.005) and spinal/epidural anesthesia (p < 0.02) to be associated with increased perioperative morbidity, and older age (p < 0.05) and higher ASA classification (p < 0.02) to be associated with severe complications requiring removal of implant. Multivariate analysis revealed only older age (p < 0.01) to be significantly related to perioperative morbidity. CONCLUSIONS Fever of > 100.5 was seen in 24% of implants and can be managed successfully without removal of the implant in 96% of cases. Use of antibiotics preoperatively and intraoperatively did not reduce the risk of perioperative temperature elevation. Use of routine diphenoxylate hydrochloride prophylaxis was tolerated without ileus or gastrointestinal obstruction clinically. Although routine deep-vein thrombosis prophylaxis is reasonable, our data would support a low risk of deep-vein thrombosis for untreated patients. Severe perioperative morbidity necessitated premature implant removal in only 5% of cases and was related to older age in multivariate analysis.
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Affiliation(s)
- R Lanciano
- Fox Chase Cancer Center, Philadelphia, PA
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Stitt JA, Fowler JF, Thomadsen BR, Buchler DA, Paliwal BP, Kinsella TJ. High dose rate intracavitary brachytherapy for carcinoma of the cervix: the Madison system: I. Clinical and radiobiological considerations. Int J Radiat Oncol Biol Phys 1992; 24:335-48. [PMID: 1526873 DOI: 10.1016/0360-3016(92)90690-j] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The decision to use five high dose rate intracavitary (HDR-ICR) insertions at weekly intervals for invasive carcinoma of the cervix treated at the University of Wisconsin Comprehensive Cancer Center (UWCCC) was made clinically. It was based on practical considerations and on previous clinical experience worldwide which showed that between 2 and 16 insertions have been used with apparently acceptable results. Although radiobiological considerations favor a large number of small doses, such a large number of HDR-ICR insertions is not clinically practical. Our strategy was to keep the biological effects of external beam and intracavitary insertions in the same ratio as used on a large series of patients treated here with low dose rate (LDR) therapy. This means keeping the same external beam treatment scheme and finding high dose rate (HDR) doses that are biologically equivalent to the previous LDR therapy, as far as possible. External beam and HDR intracavitary dose schedules for the Madison System of treating cervical carcinoma are described in detail. Because there is more repairable damage in late-reacting normal tissues, there is a bigger loss of sparing in these tissues than in tumors when changing from LDR to HDR, so total doses should be reduced more for equal late complications than for equal tumor control. The clinical decision was made to aim at equal tumor control. The possible increase in late complications has to be avoided by reducing the doses to critical normal tissues using extremely careful anatomic positioning of the HDR sources. Critical normal tissues must be kept further away from the radiation sources so that their doses are about 20% lower than with LDR geometry. This requires an extra separation of some millimeters depending on the anatomy and geometry of the individual insertion. The strategy is that the unfavourable radiobiological effects of a few large fractions must be counteracted by better physical dose distributions with HDR-ICR than with the previous LDR insertions. These good distributions are obtainable with the short exposures at HDR.
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Affiliation(s)
- J A Stitt
- Department of Human Oncology, University of Wisconsin School of Medicine, Madison
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