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Sarwar A, Syed L, Patel K, Reid I, Abonyi E, Banas N, Lowe G, Bryant L, Hoskin P. Image-guided Interstitial Brachytherapy in the Treatment of Primary and Recurrent Vulvovaginal Gynaecological Malignancies. Clin Oncol (R Coll Radiol) 2024; 36:6-11. [PMID: 37923687 DOI: 10.1016/j.clon.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
AIMS To evaluate the use, outcomes and toxicities of high dose rate brachytherapy (HDRB) to the vulvovaginal region in previously irradiated and radiotherapy-naïve patients for primary or recurrent gynaecological malignancies. MATERIALS AND METHODS From January 2010 to December 2020, 94 women with a median age of 64 years (range 31-88 years) were treated with interstitial HDRB for vulvovaginal disease. Treatment details, including cumulative radiotherapy doses, were recorded together with reported toxicity, using Common Terminology Criteria for Adverse Events (CTCAE) grading. Dosimetric parameters, including D90, V100 and V150 together with treatment response at 3 months, overall survival, relapse-free survival and long-term toxicity data, were collated from referring centres. RESULTS The median follow-up was 78 months (range 2-301). Primary sites of disease included vagina (37), endometrium (29), vulva (16), ovary (7) and cervix (5). Eighty-six (91.5%) patients were treated with curative intent, eight (8.5%) were palliative treatments. Fifty patients received HDRB for recurrent disease, 39 patients for primary disease and five as part of adjuvant treatment. The anatomical site of disease treated with HDRB ranged from vagina (76), vulva (14) and peri-urethral sites (four). The 2- and 5-year local relapse-free survival rates were 76% and 72%, respectively; 15 patients experienced local failure only, whereas six patients had local and nodal/distant failure. The median time to local recurrence was 8 months (range 2-88 months). The 2- and 5-year overall survival rates for all patients were 67% and 47%, respectively; the median overall survival was 59 months. Seventy-nine (84%) patients had a complete response measured with imaging at 3 months. Grade 3 toxicity was reported in 14 patients (14.8%). CONCLUSION This retrospective series suggests the use of interstitial brachytherapy for vulvovaginal gynaecological malignancy to be an effective and safe treatment option. Good local control was achieved with a tolerable toxicity profile; it is a valuable treatment modality.
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Affiliation(s)
- A Sarwar
- Mount Vernon Cancer Centre, Northwood, UK.
| | - L Syed
- Mount Vernon Cancer Centre, Northwood, UK
| | - K Patel
- Mount Vernon Cancer Centre, Northwood, UK
| | - I Reid
- Mount Vernon Cancer Centre, Northwood, UK
| | - E Abonyi
- Mount Vernon Cancer Centre, Northwood, UK
| | - N Banas
- Mount Vernon Cancer Centre, Northwood, UK
| | - G Lowe
- Mount Vernon Cancer Centre, Northwood, UK
| | - L Bryant
- Mount Vernon Cancer Centre, Northwood, UK
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, UK
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Shimbo T, Yoshida K, Nakata M, Kobata K, Ogawa T, Kihara A, Sato C, Hori A, Takeno S, Yoshioka H, Akiyama H, Nihei K. KORTUC, a novel hydrogen peroxide‑based radiosensitizer for the enhancement of brachytherapy in patients with unresectable recurrent uterine cervical cancer. Oncol Lett 2023; 26:378. [PMID: 37559582 PMCID: PMC10407862 DOI: 10.3892/ol.2023.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023] Open
Abstract
Kochi Oxydol Radiation Therapy for Unresectable Carcinoma (KORTUC) is a novel radiosensitizer invented by Professor Ogawa at Kochi University (Japan) in 2006. The current study aimed to report the experience of the present authors with the use of KORTUC treatment in combination with interstitial brachytherapy (ISBT), with or without external beam (EB) radiotherapy (RT), in patients with locally recurrent cervical cancer (LRCC), who were likely to have a high risk of poor prognosis. Between April 2012 and January 2020, 14 female patients (15 tumoral lesions) with LRCC underwent KORTUC with ISBT. Their previous treatments included surgery (n=4), radiation therapy (n=8) and surgery plus RT (n=3). The primary lesions were located in the vaginal stump (n=5), pelvic wall (n=3), cervix (n=3), vaginal wall (n=2) and lymph nodes (n=2). At 2 h before RT, KORTUC was injected intratumorally via direct colposcopy. The dose of KORTUC ranged from 4-12 ml, adjusted for the tumor size. For patients who underwent ISBT, KORTUC was administered before and after insertion of the applicator before irradiation. Intratumoral injection of KORTUC was completed without any technical or safety issues in all 15 patients; it was well tolerated with no adverse events observed. KORTUC also showed preferable efficacy; a clinical complete response was observed in 87% of patients and the initial response rate was 100%. The 2-year local control rate in patients who underwent ISBT + KORTUC was 79%, whereas it was 63% in the re-irradiation group which was significantly lower (P=0.02) than that in the non-irradiation group (100%). Based on this finding, KORTUC with external irradiation is considered to be an optimal treatment strategy for patients with newly diagnosed LRCC this disease. Additionally, KORTUC may be an effective radiation response enhancer in multiple cancer types in which locoregional control after RT alone remains poor.
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Affiliation(s)
- Taiju Shimbo
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Ken Yoshida
- Department of Radiology, Kansai Medical University Medical Center, Moriguti, Osaka 573-1121, Japan
| | - Mio Nakata
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Kazuma Kobata
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Takashi Ogawa
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Ayaka Kihara
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Chikara Sato
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Akihiro Hori
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Satoshi Takeno
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Hiroto Yoshioka
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
| | - Hironori Akiyama
- Department of Dental Radiology, Osaka Dental University, Hirakata, Osaka 570-8507, Japan
| | - Keiji Nihei
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Takatuki, Osaka 569-8686, Japan
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High-dose-rate interstitial brachytherapy with hypoxic radiosensitizer KORTUC II for unresectable pelvic sidewall recurrence of uterine cervical cancer: a case report. J Contemp Brachytherapy 2021; 12:606-611. [PMID: 33437310 PMCID: PMC7787211 DOI: 10.5114/jcb.2020.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/16/2020] [Indexed: 11/25/2022] Open
Abstract
In order to improve oncologic outcomes in radiotherapy treatments of patients with unresectable pelvic sidewall recurrences of uterine cervical cancer, we combined high-dose-rate interstitial brachytherapy (HDR-ISBT) with newly tested hypoxic radiosensitizer Kochi oxydol-radiation therapy for unresectable carcinomas (KORTUC II), an enzyme-targeting radiosensitization treatment involving intra-tumoral injection of sodium hyaluronate mixed with hydrogen peroxide. We report on a 63-year-old patient referred to our department with an extensive pelvic sidewall recurrence of uterine cervical cancer after initial hysterectomy. The tumor size was 55 × 25 × 80 mm, with a calculated volume of 89.7 cc. Whole pelvic irradiation of 50 Gy in 25 fractions was administered, combined with weekly cisplatin injections. KORTUC II injections were given two times: at day 21 (42 Gy) and at day 24 (48 Gy). After finishing whole pelvic irradiation, HDR-ISBT of 25 Gy in 5 fractions b.i.d. over 3 days was administered. KORTUC II was also injected at the time of implantation. Dose-volume histogram (DVH) values for clinical target volume were D90, D98, and D100 of 6.0, 5.0, and 3.5 Gy per fraction, respectively. D2cc values were 2.1, 4.1, 3.2, and 2.0 Gy per fraction for the bladder, rectum, sigmoid colon, and small bowel, respectively. No acute adverse events ≥ grade 3 were observed. Repeated grade 3 pyelonephritis occurred as a late complication at 11, 24, and 26 months after the treatment, and was successfully resolved with antibiotics. Moreover, grade 2 late toxicity was documented, including sciatic neuralgia, lower limb lymphedema, and urinary incontinence. At present, 32 months after HDR-ISBT, the patient remains free of disease, with no toxicity-related deterioration in physical condition.
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Jia AY, Viswanathan AN. Vaginal necrosis: A rare late toxicity after radiation therapy. Gynecol Oncol 2020; 160:602-609. [PMID: 33303211 DOI: 10.1016/j.ygyno.2020.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/23/2020] [Indexed: 01/22/2023]
Abstract
Vaginal necrosis is a late radiation tissue injury with serious morbidity complications. It is rare, and its incidence is not well assessed in prospective trials. Patient comorbidities and radiation dose can significantly increase the risk. As treatment of gynecologic malignancies often involve a multidisciplinary approach, timely diagnosis and appropriate management by physicians of the team are crucial. Untreated vaginal necrosis can lead to infection, hemorrhage, necrosis-related fistulation to the bladder or rectum, perforation, and death. In this review, we describe the pathophysiology of vaginal necrosis, its clinical course, and management options.
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Affiliation(s)
- Angela Y Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, United States of America
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, United States of America.
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Chapman CH, Maghsoudi K, Littell RD, Chen LM, Hsu IC. Salvage high-dose-rate brachytherapy and external beam radiotherapy for isolated vaginal recurrences of endometrial cancer with no prior adjuvant therapy. Brachytherapy 2017; 16:1152-1158. [DOI: 10.1016/j.brachy.2017.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/26/2017] [Accepted: 07/05/2017] [Indexed: 11/28/2022]
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Feddock J, Cheek D, Steber C, Edwards J, Slone S, Luo W, Randall M. Reirradiation Using Permanent Interstitial Brachytherapy: A Potentially Durable Technique for Salvaging Recurrent Pelvic Malignancies. Int J Radiat Oncol Biol Phys 2017; 99:1225-1233. [PMID: 29029888 DOI: 10.1016/j.ijrobp.2017.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/31/2017] [Accepted: 08/21/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To present a time-to-failure (TTF) analysis for all patients treated with permanent interstitial brachytherapy (PIB) at our institution, with additional analyses to correlate successful reirradiation and to identify the frequency of severe grade 3 to 4 toxicity. METHODS AND MATERIALS Forty-two previously irradiated patients received curative or palliative intent PIB for a recurrent pelvic malignancy between January 2009 and August 2016. Minimum follow-up was 6 months after the PIB procedure. All patients had a biopsy-proven recurrence and were treated using PIB alone (n=32) or in combination with a short course of additional radiation therapy (n=10). Competing risk analyses were performed to assess the risk of failures in the presence of death without failure. Exploratory analyses were performed for factors related to failure using competing risk analyses and the Gray statistic. RESULTS A total of 61 PIB implants were performed among 42 patients with a median follow-up of 16.3 months. Fifty-two implants were performed as the first salvage reirradiation to a solitary recurrence (8 patients had more than 1 lesion); the success rate for initial reirradiation using PIB was 73% (38 cases out of 52), and the median TTF was not reached. Nine patients underwent a second repeat PIB to the same recurrence as a form of salvage; 3 (33%) remain without evidence of recurrence. The median TTF after second salvage was 7.7 months. Even with the limited sample size, prolonged TTF was marginally associated with definitive intent (P=.07) and the extent of disease at the time of PIB (P=.08). Grade 3+ toxicities were seen in 8 patients (16.7%). CONCLUSIONS Permanent interstitial brachytherapy is a feasible and potentially durable treatment modality that can be used to curatively salvage selected recurrent pelvic malignancies in a previously irradiated field.
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Affiliation(s)
- Jonathan Feddock
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Lexington, Kentucky.
| | - Dennis Cheek
- Division of Medical Physics, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Cole Steber
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Jason Edwards
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Stacey Slone
- Department of Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Wei Luo
- Division of Medical Physics, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Marcus Randall
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
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Chen KS, Glaser SM, Kim H, Beriwal S. Differences in urethral dosimetry between CT and MR imaging in multichannel vaginal cylinder brachytherapy. Brachytherapy 2017; 16:964-967. [PMID: 28694115 DOI: 10.1016/j.brachy.2017.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/18/2017] [Accepted: 06/01/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE In image-based brachytherapy (IBBT), the dosimetry of small structures may be particularly sensitive to changes in contouring between imaging modalities. We therefore sought to characterize differences in urethral dosimetry in vaginal brachytherapy based on contouring on MRI vs. CT. METHODS AND MATERIALS We retrospectively identified our most recent 15 patients treated with intracavitary brachytherapy for distal vaginal malignancies. On T2-weighted MRI, both the lumen and urethral wall were contoured. On CT, the urethral lumen alone was contoured, as the wall is indistinguishable from surrounding tissue. High-dose-rate (HDR) IBBT plans were generated for all patients. RESULTS Mean urethral volume was higher on MRI than CT at 3.7 cc vs. 1.1 cc (p < 0.0005). As a result, there were statistically significant increases on MRI in D0.1cc and D0.5cc, as well as EQD2 D0.1cc and EQD2 D0.5cc when applied to a full course of treatment (45 Gy EBRT + 25 Gy IBBT). CONCLUSIONS We have quantified the expected differences in urethral volume and dosimetry when contoured on MRI vs. CT. Inclusion of the urethral wall on MRI, with its average thickness of 2.2 mm, likely more accurately reflects the true organ at risk and results in an increase in reported dose compared to CT.
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Affiliation(s)
| | - Scott M Glaser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Hayeon Kim
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA.
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Baek S, Isohashi F, Yamaguchi H, Mabuchi S, Yoshida K, Kotsuma T, Yamazaki H, Tanaka E, Sumida I, Tamari K, Otani K, Seo Y, Suzuki O, Yoshioka Y, Kimura T, Ogawa K. Salvage high-dose-rate brachytherapy for isolated vaginal recurrence of endometrial cancer. Brachytherapy 2016; 15:812-816. [DOI: 10.1016/j.brachy.2016.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/20/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
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Shin SM, Duckworth TL, Cooper BT, Curtin JP, Schiff PB, DeWyngaert JK, Lymberis SC. Use of a Flexible Inflatable Multi-Channel Applicator for Vaginal Brachytherapy in the Management of Gynecologic Cancer. Front Oncol 2015; 5:201. [PMID: 26442213 PMCID: PMC4568766 DOI: 10.3389/fonc.2015.00201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/31/2015] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Evaluate use of novel multi-channel applicator (MC) Capri™ to improve vaginal disease coverage achievable by single-channel applicator (SC) and comparable to Syed plan simulation. MATERIALS AND METHODS Twenty-eight plans were evaluated from four patients with primary or recurrent gynecologic cancer in the vagina. Each received whole pelvis radiation, followed by three weekly treatments using HDR brachytherapy with a 13-channel MC. Upper vagina was treated to 5 mm depth to 1500 cGy/3 fractions with a simultaneous integrated boost totaling 2100 cGy/3 fractions to tumor. Modeling of SC and Syed plans was performed using MC scans for each patient. Dosimetry for MC and SC plans was evaluated for PTV700 cGy coverage, maximum dose to 2 cm(3) to bladder, rectum, as well as mucosal surface points. Dosimetry for Syed plans was calculated for PTV700 cGy coverage. Patients were followed for treatment response and toxicity. RESULTS Dosimetric analysis between MC and SC plans demonstrated increased tumor coverage (PTV700 cGy), with decreased rectal, bladder, and contralateral vaginal mucosa dose in favor of MC. These differences were significant (p < 0.05). Comparison of MC and Syed plans demonstrated increased tumor coverage in favor of Syed plans which were not significant (p = 0.71). Patients treated with MC had no cancer recurrence or ≥grade 3 toxicity. CONCLUSION Use of MC was efficacious and safe, providing superior coverage of tumor volumes ≤1 cm depth compared to SC and comparable to Syed implant. MC avoids excess dose to surrounding organs compared to SC, and potentially less morbidity than Syed implants. For tumors extending ≤1 cm depth, use of MC represents an alternative to an interstitial implant.
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Affiliation(s)
- Samuel M Shin
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - Tamara L Duckworth
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - Benjamin T Cooper
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - John P Curtin
- Department of Obstetrics and Gynecology, NYU Langone Medical Center , New York, NY , USA
| | - Peter B Schiff
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - J Keith DeWyngaert
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - Stella C Lymberis
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
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Amsbaugh MJ, Bhatt N, Hunter T, Gaskins J, Parker L, Metzinger D, Amsbaugh A, Sowards K, El-Ghamry M. Computed tomography planned interstitial brachytherapy for recurrent gynecologic cancer. Brachytherapy 2015; 14:600-5. [PMID: 26087868 DOI: 10.1016/j.brachy.2015.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/14/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To report outcomes and identify predictors of toxicity in patients undergoing reirradiation with interstitial brachytherapy (ISBT) for recurrent cancers of the female reproductive tract. METHODS AND MATERIALS Twenty-one patients received ISBT performed using (192)Ir sources (10 low dose rate and 11 high dose rate) at our institution between 2009 and 2013. Demographic, disease specific, treatment, toxicity, and outcome data were collected. Kaplan-Meier and proportional hazard models were used to estimate survival and logistic regression to model toxicity. A least absolute shrinkage and selection operator penalty was used to identify relevant predictors of outcome and toxicity. RESULTS Eleven patients had uterine cancer, 7 patients had cervical cancer, and 3 patients had vulvar cancer. One-year actuarial freedom from local-regional failure, progression-free survival (PFS), and overall survival were 71.5%, 66.0%, and 82.2%, respectively. Tumor size was a significant predictor of worse PFS and overall survival (1 cm increase in tumor size = hazard ratio [HR], 1.61; 95% confidence interval [CI]: 1.16, 2.62 for PFS; HR, 2.02; 95% CI: 1.21, 3.38). Grade 3 or higher vaginal, urinary, and rectal toxicity occurred in 28.5%, 9.5%, and 19% of patients, respectively. Urethra D0.1cc predicted for grade 2 or higher urinary toxicity (one equivalent dose in 2 Gy fraction increase = HR, 1.156; 95% CI: 1.001, 1.335). CONCLUSIONS Reirradiation with ISBT is both safe and effective. In patients with recurrent cancer, urethra D0.1cc predicts for increased urinary toxicity. Increased tumor size is a negative prognostic factor in patients receiving ISBT for cancer recurrence.
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Affiliation(s)
- Mark J Amsbaugh
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Neal Bhatt
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Thomas Hunter
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Lynn Parker
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Daniel Metzinger
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Ashley Amsbaugh
- Department of Anesthesia and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Keith Sowards
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Moataz El-Ghamry
- Department of Radiation Oncology, University of Louisville, Louisville, KY.
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Intraoperative radiation therapy (IORT) for gynecologic malignancies. Gynecol Oncol 2015; 138:449-56. [PMID: 26033307 DOI: 10.1016/j.ygyno.2015.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/22/2015] [Accepted: 05/26/2015] [Indexed: 01/15/2023]
Abstract
Every year almost 95,000 women are diagnosed with a gynecologic malignancy and over 28,000 women will succumb to their disease. For patients with an isolated locoregional recurrence after primary therapy, surgical resection may sometimes provide a chance of cure. To optimize the chance of local control intraoperative radiation therapy (IORT) has been used. The combination of salvage surgery and IORT has resulted in reasonable control in the IORT field. The addition of external beam radiation to limited volumes seems to result in improved disease control over surgery and IORT alone. Side effects are closely related to radical surgery, although neuropathy is seen more frequently after IORT; especially if doses of >20Gy are prescribed. Margin status remains critical, even with IORT.
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Treatment results of image-guided high-dose-rate interstitial brachytherapy for pelvic recurrence of uterine cancer. Brachytherapy 2015; 14:440-8. [PMID: 25858904 DOI: 10.1016/j.brachy.2015.02.195] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/12/2015] [Accepted: 02/12/2015] [Indexed: 11/21/2022]
Abstract
PURPOSE We analyzed clinical data to evaluate the effectiveness of image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for pelvic recurrence of uterine cancer. METHODS AND MATERIALS Between 2003 and 2011, 56 patients were treated with HDR-ISBT with or without external beam radiotherapy (EBRT). The median followup time was 33 months (range, 1-109 months). Pre-ISBT treatments included radical hysterectomy for 35 patients (Group A), radical hysterectomy with postoperative radiotherapy for 8 patients (Group B), and radical radiotherapy for 13 patients (Group C). We initiated MRI-assisted CT-based planning for the last 49 patients. The median ISBT single fraction dose was 6 Gy. The median total doses were 30 and 54 Gy with and without EBRT (range, 30-50 Gy) for Group A, respectively and 48 Gy without EBRT for Groups B and C. RESULTS The 3-year local control (LC) rates were 85%, 75%, and 46% for Groups A, B, and C, respectively (p = 0.017). The 3-year LC rates were 84%, 73%, and 33% for clinical target volume at the time of HDR-ISBT of <10, 10-29, and ≥30 cc, respectively (p = 0.005). The 3-year LC results tended to be higher for patients whose D100 (clinical target volume) was equal or higher than 67.1 Gy (p = 0.098). A total of 13 late complications of Grades 3-5 occurred in 11 patients (20%). CONCLUSIONS Our image-guided HDR-ISBT for pelvic recurrence of uterine cancer provided good treatment outcomes. The treatment results for patients who underwent radical surgery with or without postoperative radiotherapy are better than those for patients who underwent radical radiotherapy.
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Outpatient-based high-dose-rate interstitial brachytherapy for gynecologic malignancies. Brachytherapy 2015; 14:231-7. [DOI: 10.1016/j.brachy.2014.11.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 11/05/2014] [Accepted: 11/10/2014] [Indexed: 11/18/2022]
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Wooten CE, Randall M, Edwards J, Aryal P, Luo W, Feddock J. Implementation and early clinical results utilizing Cs-131 permanent interstitial implants for gynecologic malignancies. Gynecol Oncol 2014; 133:268-73. [DOI: 10.1016/j.ygyno.2014.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/05/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
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Phase II trial of image-based high-dose-rate interstitial brachytherapy for previously irradiated gynecologic cancer. Brachytherapy 2014; 13:219-24. [PMID: 24559794 DOI: 10.1016/j.brachy.2014.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/23/2014] [Accepted: 01/24/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To report the disease-free Grade ≥3 complication-free survival of a Phase II protocol of reirradiation with high-dose-rate (HDR) interstitial brachytherapy (ITB) in previously irradiated gynecologic cancer. METHODS AND MATERIALS Fifteen patients with previously irradiated cervical (n = 6), endometrial (n = 6), and vulvovaginal tumors (n = 3) were treated with HDR-ITB alone to a median dose of 38 Gy in 8 b.i.d. fractions over 4 consecutive days. Prior treatments included surgery (n = 12; 80%), external irradiation (n = 15; 100%), and brachytherapy (n = 9; 60%). Average clinical target volume Size was 60.9 cc (range, 14.8-165.3 cc), and median time to reirradiation was 3.9 years (range, 0.4-22.7 years). RESULTS With a median followup of 2.8 years (range, 1.2-9.2 years), 3 patients (20.0%) developed Grade ≥3 toxicity consisting of Grade 3 intestinal obstruction (n = 1), Grade 4 rectovesical fistula (n = 1), and Grade 5 intestinal obstruction (n = 1). Six patients remain alive and without evidence of disease at last followup. Two patients are alive with disease progression, and 7 patients have died, 4 of them from disease progression and 3 from other causes. The 2-year disease-free Grade ≥3 complication-free survival was 40%. CONCLUSIONS HDR-ITB alone is a reasonable salvage treatment option in a significant number of patients with previously irradiated gynecologic tumors.
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Lapuz C, Dempsey C, Capp A, O'Brien PC. Dosimetric comparison of optimization methods for multichannel intracavitary brachytherapy for superficial vaginal tumors. Brachytherapy 2013; 12:637-44. [PMID: 23850274 DOI: 10.1016/j.brachy.2013.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 03/27/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Multichannel vaginal applicators allow treatment of a more conformal volume compared with a single, central vaginal channel. There are several optimization methods available for use with multichannel applicators, but no previous comparison of these has been performed in the treatment of superficial vaginal tumors. Accordingly, a feasibility study was completed to compare inverse planning by simulated annealing (IPSA), dose point optimization (DPO), and graphical optimization for high-dose-rate brachytherapy using a multichannel, intracavitary vaginal cylinder. METHODS AND MATERIALS This comparative study used CT data sets from five patients with superficial vaginal recurrences of endometrial cancer treated with multichannel intracavitary high-dose-rate brachytherapy. Treatment plans were generated using DPO, graphical optimization, surface optimization with IPSA (surf IPSA), and two plans using volume optimization with IPSA. The plans were evaluated for target coverage, conformal index, dose homogeneity index, and dose to organs at risk. RESULTS Best target coverage was achieved by volume optimization with IPSA 2 and surf IPSA with mean V100 values of 93.89% and 91.87%, respectively. Doses for the most exposed 2-cm(3) of the bladder (bladder D2cc) was within tolerance for all optimization methods. Rectal D2cc was above tolerance for one DPO plan. All volume optimization with IPSA plans resulted in higher vaginal mucosa doses for all patients. Greatest homogeneity within the target volume was seen with surf IPSA and DPO. Highest conformal indices were seen with surf IPSA and graphical optimization. CONCLUSIONS Optimization with surf IPSA was user friendly for the generation of treatment plans and achieved good target coverage, conformity, and homogeneity with acceptable doses to organs at risk.
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Affiliation(s)
- Carminia Lapuz
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia; Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
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Beriwal S, Rwigema JCM, Higgins E, Kim H, Houser C, Sukumvanich P, Olawaiye A, Richard S, Kelley JL, Edwards RP, Krivak TC. Three-dimensional image-based high-dose-rate interstitial brachytherapy for vaginal cancer. Brachytherapy 2012; 11:176-80. [DOI: 10.1016/j.brachy.2011.05.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/16/2011] [Accepted: 05/18/2011] [Indexed: 11/30/2022]
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Image and laparoscopic guided interstitial brachytherapy for locally advanced primary or recurrent gynaecological cancer using the adaptive GEC ESTRO target concept. Radiother Oncol 2011; 100:473-9. [PMID: 21924784 DOI: 10.1016/j.radonc.2011.08.016] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Revised: 08/19/2011] [Accepted: 08/20/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE To retrospectively assess treatment outcome of image and laparoscopic guided interstitial pulsed dose rate brachytherapy (PDR-BT) for locally advanced gynaecological cancer using the adaptive GEC ESTRO target concept. MATERIALS AND METHODS Between June 2005 and December 2010, 28 consecutive patients were treated for locally advanced primary vaginal (nine), recurrent endometrial (12) or recurrent cervical cancer (seven) with combined external beam radiotherapy (EBRT) and interstitial PDR-BT. Treatment was initiated with whole pelvic EBRT to a median dose of 45 Gy followed by PDR-BT using the Martinez Universal Perineal Interstitial Template (MUPIT). All implants were virtually preplanned using MRI of the pelvis with a dummy MUPIT in situ. The GEC ESTRO high risk clinical target volume (HR CTV), intermediate risk clinical target volume (IR CTV) and the organs at risk (OAR) were contoured and a preplan for implantation was generated (BrachyVision, Varian). The subsequent implantation was performed under laparoscopic visualisation. Final contouring and treatment planning were done using a post-implant CT. Planning aim of PDR-BT was to deliver 30 Gy in 50 hourly pulses to HR CTV. Manual dose optimisation was performed with the aim of reaching a D90>80 Gy in the HR CTV calculated as the total biologically equivalent to 2 Gy fractions of EBRT and BT (EQD2). Dose to the OAR were evaluated using dose volume constraints for D(2cc) of 90 Gy for bladder and 70 Gy for rectum and sigmoid. RESULTS For HR CTV the median volume was 26 cm(3) (7-91 cm(3)). Coverage of the HR CTV was 97% (90-100%) and D90 was 82 Gy (77-88 Gy). The D(2cc) for bladder, rectum, and sigmoid were 65 Gy (47-81 Gy), 61 Gy (50-77 Gy), and 52 Gy (44-68 Gy), respectively. Median follow up was 18 months (6-61 months). The actuarial 2 years local control rate was 92% (SE 5), while disease-free survival and overall survival were 59% (SE 11) and 74%, respectively (SE 10). No complications to the laparoscopic guided implantation were encountered. Late grade 2 (CTC v 3.0) complications were recorded in nine (32%) patients. One patient had a grade 3 vaginal complication. No grade 4-5 complications have been recorded so far. CONCLUSION Image and laparoscopic guided interstitial PDR-BT using the GEC ESTRO target concept is applicable for locally advanced primary vaginal or recurrent endometrial and cervical cancer resulting in an excellent local control rate and limited morbidity.
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Inverse-planned gynecologic high-dose-rate interstitial brachytherapy: clinical outcomes and dose--volume histogram analysis. Brachytherapy 2011; 11:181-91. [PMID: 21862418 DOI: 10.1016/j.brachy.2011.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 06/01/2011] [Accepted: 06/16/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE To present clinical outcomes and dose-volume histogram parameters of three-dimensional image-based high-dose-rate interstitial brachytherapy (HDR-ISBT) in patients with primary or recurrent gynecologic cancer unsuitable for intracavitary brachytherapy (ICB). METHODS AND MATERIALS Records of 43 women treated between 2001 and 2009 with iridium-192 gynecologic HDR-ISBT boost, using a Syed-Neblett template and inverse planning simulated annealing dose optimization, were reviewed. Median HDR-ISBT dose was 30Gy, delivered in 4-6Gy/fraction. Dose-volume histogram parameters recommended by the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology for image-based ICB were analyzed. Total doses were normalized to 2Gy fractions (biologically equivalent dose in 2Gy fractions). Local control (LC) and survival were calculated using Kaplan-Meier method. Toxicities were defined according to Common Terminology Criteria for Adverse Events v3.0. RESULTS There were 34 primary malignancies (cervix=12, vagina=15, Bartholin's gland=5, and vulva=2) and 9 recurrences. International Federation of Gynecology and Obstetrics stage distribution for primary cancers was I=2, II=13, III=15, and IV=4. Median followup was 19.3 months (range, 0-92.2). Two-year LC was 87% for primary cancers, and 45% for recurrent cancers, respectively (p=0.0175). Median V(100), D(90), and D(100) for clinical target volume were 97.6%, 90.2, and 68.7Gy(10), respectively. Median bladder and rectal D(2)(cc) were 76.6 and 79.5Gy(3), respectively. Median urethral D(10) was 80.6Gy(3). Twelve patients experienced Grades 3 and 4 late morbidity, but toxicities were transient. Only 2 patients had persistent severe toxicities. A trend toward increased risk for vaginal necrosis was observed with a clinical target volume >84cc. CONCLUSIONS HDR-ISBT may achieve good LC in gynecologic cancer unsuitable for ICB, especially in primary malignancies with a 2-year LC rate higher than 85%. Delivery of such high doses has potential advantages but may predispose to adverse effects, reversible in most cases.
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Kotsuma T, Yoshida K, Yamazaki H, Takenaka T, Konishi K, Isohashi F, Koizumi M, Tanaka E, Yoshioka Y. Preliminary results of magnetic resonance imaging-aided high-dose-rate interstitial brachytherapy for recurrent uterine carcinoma after curative surgery. JOURNAL OF RADIATION RESEARCH 2011; 52:329-334. [PMID: 21467737 DOI: 10.1269/jrr.10172] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This report presents initial experience with imaging-aided high-dose-rate interstitial brachytherapy (HDR-ISBT) for post-operative recurrence of uterine carcinoma. Fourteen patients presenting with post-operative recurrence of uterine carcinoma (nine cervix and five corpus) between July 2005 and October 2008 were enrolled in this study (median follow-up: 37 months, range: 6-59 months). We implanted magnetic resonance imaging (MRI)-compatible plastic applicators using our own ambulatory technique. HDR-ISBT treatment consisted of twice-a-day irradiation of 6 Gy each with at least a six-hour interval to provide the total prescribed dose. Treatment was based on treatment planning-computed tomography with MRI as a reference. Seven patients were treated with a combination of ISBT (median 30 Gy/5 fractions; range: 27-33 Gy) and external beam radiation therapy (EBRT), and the other seven with brachytherapy only (median 54 Gy/9 fractions; range: 48-54 Gy), one of whom had previously received pelvic EBRT. The three-year estimates of local control and overall survival rates were 77.9% (95% confidence interval (CI): 55.8-100%) and 77.1% (95% CI: 54.2-100%), respectively. Two patients, who had received combined treatment with EBRT showed untoward reactions, including a grade 3 subileus and grade 2 constipation. Another patient, who had been treated with ISBT alone, developed grade 2 urinary constriction. Our imaging-aided HDR-ISBT for post-operative recurrence of uterine carcinoma was found to be practical with promising preliminary results.
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Affiliation(s)
- Tadayuki Kotsuma
- Department of Radiation Oncology, Osaka University Graduate School of Medicine
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Rauh-Hain JA, Del Carmen MG. Treatment for advanced and recurrent endometrial carcinoma: combined modalities. Oncologist 2010; 15:852-61. [PMID: 20660059 DOI: 10.1634/theoncologist.2010-0091] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Women with recurrent or advanced endometrial cancer constitute a heterogeneous group of patients. Depending on previous treatment, women with recurrent endometrial cancer may be appropriate candidates for surgery, radiation therapy, hormonal therapy, or chemotherapy. Women with advanced stage disease at presentation may also be appropriate candidates for systemic and local therapies. We review the treatment options available to treat recurrent and locally advanced endometrial cancer. Treatment choice depends largely on the localization of disease, the patient's performance status and previous treatment history, as well the tumor's hormonal receptor status. Radiation therapy is appropriate for isolated vaginal recurrences in patients with no previous history of radiation therapy. Patients with recurrent low-grade tumors overexpressing estrogen and progesterone receptors may be treated with progestin therapy. Systemic therapy is appropriate for patients with disseminate recurrences or advanced stage disease at presentation, or for those with receptor-negative tumors. We review all these different treatment strategies available to patients with advanced or recurrent endometrial cancer.
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Affiliation(s)
- J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 9 E, Boston, MA 02114, USA
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van Wijk F, van der Burg M, Burger CW, Vergote I, van Doorn HC. Management of Recurrent Endometrioid Endometrial Carcinoma: An Overview. Int J Gynecol Cancer 2009; 19:314-20. [DOI: 10.1111/igc.0b013e3181a7f71e] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In this paper, an overview of the literature on the management of recurrent endometrial cancer is presented, focusing on patients with histopathologic endometrioid type of tumors. The different treatment modalities are described, and a management recommendation scheme is presented. Indications for surgical treatment depend on resectability, site and size of the tumor, and performance status of the patient. Indications for radiotherapy depend on the site of the recurrence and also on the initial therapy received. When considering systemic treatment for patients with recurrent endometrial cancer, it is important to take into account the general health status and condition of the patient as well as which prior therapy the patient has received. The treatments of choice for patients with hormone-sensitive tumors (positive receptor levels, low-grade tumors, and long disease-free interval) are progestagens as first-line treatment and tamoxifen as second-line treatment. Patients with high-grade tumors, negative hormone receptor levels, and short treatment-free interval are best treated with chemotherapy. Paclitaxel, doxorubicin, and cisplatin are the most active combination therapy for these patients but with significant toxicity. In phase II studies, the combination therapy with paclitaxel and carboplatin seems to be as effective but less toxic and can be administered in outpatient clinic. The literature on the management of patients with recurrent endometrial cancer is discussed in detail. The different sites of recurrent disease (ie, local, regional, and/or distant) are evaluated separately; management recommendations are proposed, and alternative approaches are given.
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Haasbeek CJ, Uitterhoeve AL, van der Velden J, González DG, Stalpers LJ. Long-term results of salvage radiotherapy for the treatment of recurrent cervical carcinoma after prior surgery. Radiother Oncol 2008; 89:197-204. [DOI: 10.1016/j.radonc.2008.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Revised: 11/22/2007] [Accepted: 01/03/2008] [Indexed: 11/24/2022]
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Beriwal S, Heron DE, Mogus R, Edwards RP, Kelley JL, Sukumvanich P. High-dose rate brachytherapy (HDRB) for primary or recurrent cancer in the vagina. Radiat Oncol 2008; 3:7. [PMID: 18271958 PMCID: PMC2270281 DOI: 10.1186/1748-717x-3-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 02/13/2008] [Indexed: 01/02/2023] Open
Abstract
Purpose The purpose of this study was to evaluate the efficacy of HDR brachytherapy for primary or recurrent vaginal cancer. Methods Between the years 2000 to 2006, 18 patients with primary or recurrent vaginal cancer were treated with brachytherapy (HDRB). Six patients had primary vaginal cancer (stage II to IVA) while 12 were treated for isolated vaginal recurrence (primary cervix = 4, vulva = 1 and endometrium = 7). Five patients had previous pelvic radiation therapy. All except one patient received external beam radiation therapy to a median dose of 45 Gy (range 31.2–55.8 Gy). The HDRB was intracavitary using a vaginal cylinder in 5 patients and interstitial using a modified Syed-Nesblett template in 13 patients. The dose of interstitial brachytherapy was 18.75 Gy in 5 fractions delivered twice daily. The median follow-up was 18 months (range 6–66 months). Results Complete response (CR) was achieved in all but one patient (94%). Of these 17 patients achieving a CR, 1 had local recurrence and 3 had systemic recurrence at a median time of 6 months (range 6–22 months). The 2-year actuarial local control and cause-specific survival for the entire group were 88% and 82.5%, respectively. In subset analysis, the crude local control was 100% for primary vaginal cancer, 100% for the group with recurrence without any prior radiation and 67% for group with recurrence and prior radiation therapy. Two patients had late grade 3 or higher morbidity (rectovaginal fistula in one patient and chronic vaginal ulcer resulting in bleeding in one patient). Both these patients had prior radiation therapy. Conclusion Our small series suggests that HDRB is efficacious for primary or recurrent vaginal cancer. Patients treated with primary disease and those with recurrent disease without prior irradiation have the greatest benefit from HDRB in this setting. The salvage rate for patients with prior radiation therapy is lower with a higher risk of significant complications. Additional patients and follow-up are ongoing to determine the long-term efficacy of this approach.
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Affiliation(s)
- Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA.
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Viswanathan AN, Cormack R, Holloway CL, Tanaka C, O'Farrell D, Devlin PM, Tempany C. Magnetic resonance–guided interstitial therapy for vaginal recurrence of endometrial cancer. Int J Radiat Oncol Biol Phys 2006; 66:91-9. [PMID: 16839709 DOI: 10.1016/j.ijrobp.2006.04.037] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 04/05/2006] [Accepted: 04/06/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate the feasibility and to describe the acute toxicity of a real-time intraoperative magnetic resonance (MR)-image guided interstitial approach to treating vaginal recurrence of endometrial cancer. METHODS AND MATERIALS From February 2004 to April 2005, 10 patients with recurrent endometrial cancer underwent MR-guided interstitial brachytherapy. Parameters evaluated included needle placement, dose-volume histograms (DVH), and complications. RESULTS Magnetic resonance-image guidance resulted in accurate needle placement. Tumor DVH values included median volume, 47 cc; V100, 89%; V150, 61%; V200, 38%; D90, 71 Gy; and D100, 60 Gy. DVH of organs at risk resulted in a median D2cc of external beam and brachytherapy dose (% of brachytherapy prescription): bladder, 75Gy(3) (88%); rectum, 70Gy(3) (87%); and sigmoid, 56Gy(3) (41%). All patients experienced either a Grade 1 or 2 acute toxicity related to the radiation; only 1 patient had Grade 3 toxicity. No toxicities were attributable to the use of MR guidance. CONCLUSIONS Real-time MR guidance during the insertion of interstitial needles reduces the likelihood of an inadvertent insertion of the needles into the bladder and the rectum. Three-dimensional dosimetry allows estimation of the dose to organs at risk. Toxicities are limited.
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Affiliation(s)
- Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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Petignat P, Jolicoeur M, Alobaid A, Drouin P, Gauthier P, Provencher D, Donath D, Van Nguyen T. Salvage treatment with high-dose-rate brachytherapy for isolated vaginal endometrial cancer recurrence. Gynecol Oncol 2006; 101:445-9. [PMID: 16386785 DOI: 10.1016/j.ygyno.2005.11.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Revised: 10/31/2005] [Accepted: 11/03/2005] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the outcome of patients with recurrent vaginal endometrial cancer treated with high-dose-rate brachytherapy (HDRB) and external beam radiation therapy (EBRT). MATERIALS AND METHODS The records of all patients diagnosed with endometrial cancer who had presented an isolated vaginal recurrence in our institution between January 1, 1997 and December 30, 2003 were reviewed. Twenty-two patients were identified; 18 (82%) received both EBRT and HDRB, and 4 (18%) received HDRB only. The median EBRT dose prescribed was 45 Gy (range: 44-50.4), and median HDRB was 26 Gy (range: 8-48). Recurrence-free intervals as well as disease-specific survival rates were noted. Complications were assessed in terms of early and late Radiation Therapy Oncology Group toxicity (grade 3 or worse) of the gastrointestinal tract, genitourinary tract and vagina. RESULTS Median age at recurrence for the 22 patients was 72 years (range: 54-86). Median recurrence time was 20 months (range: 4-135). A complete response was achieved in 100% of patients. After a median follow-up of 32 months (range: 11-78), no patient had locoregional recurrence; 1 developed distant metastasis and died from the disease. Five-year local control, disease-free survival and disease-specific survival were 100%, 96% and 96%, respectively. Four patients (18%) presented grades 3-4 gastrointestinal toxicity, and 11 (50%), grade 3 vaginal toxicity. CONCLUSION Recurrent vaginal endometrial cancer is amenable to salvage therapy with HDRB and EBRT.
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Affiliation(s)
- Patrick Petignat
- Department of Gynecologic Oncology, Centre hospitalier de l'Université de Montréal (CHUM)-Hôpital Notre-Dame, Montréal, Québec, Canada
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Dowdy SC, Mariani A, Cliby WA, Haddock MG, Petersen IA, Sim FH, Podratz KC. Radical pelvic resection and intraoperative radiation therapy for recurrent endometrial cancer: Technique and analysis of outcomes. Gynecol Oncol 2006; 101:280-6. [PMID: 16321431 DOI: 10.1016/j.ygyno.2005.10.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 10/13/2005] [Accepted: 10/19/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the technique and assess outcomes and morbidity following radical resection combined with intraoperative electron radiation therapy (IOERT) in patients with recurrent endometrial cancer. METHODS From 1986 to 2002, 25 patients received treatment including radical resection and IOERT for recurrent endometrioid, endometrial cancer. Relevant clinical information was extracted through retrospective chart review. RESULTS Treatment prior to referral included radiation in 56% and either a secondary surgery or chemotherapy in 48%. External radiation (EBRT) was administered in addition to IOERT in 84%. Radical procedures performed at the time of IOERT included resection of the pelvic sidewall en bloc with the obturator nerve, external iliac vein, psoas, iliacus, or obturator internus muscles, ureter, or boney ileum. Seven patients required exenteration in combination with resection of the pelvic sidewall. The median IOERT dose was 1500 cGy (range 1000-2500 cGy). Overall five-year survival was 47% vs. 71% for those with a gross total resection but close margins. Two patients with recurrences limited to the para-aortic area are alive without evidence of disease at 54 and 71 months. Proportional hazards modeling showed concurrent EBRT, tumor size after resection, grade, and age to be associated with improved survival. The most common complications were peripheral neuropathy, functional ureteral obstruction, and fistula formation. CONCLUSIONS With an aggressive treatment approach including radical resection combined with IOERT, long-term survival is possible in a significant number of patients with localized recurrent endometrial cancer. Preoperative radiation paired with complete surgical resection utilizing extended procedures is paramount to achieving optimal outcomes.
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Affiliation(s)
- Sean C Dowdy
- Division of Gynecologic Surgery, 200 1st St. NW, Rochester, MN 55905, USA.
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Mariani A, Dowdy SC, Keeney GL, Haddock MG, Lesnick TG, Podratz KC. Predictors of vaginal relapse in stage I endometrial cancer. Gynecol Oncol 2005; 97:820-7. [PMID: 15894363 DOI: 10.1016/j.ygyno.2005.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2004] [Revised: 03/02/2005] [Accepted: 03/09/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify factors predictive of vaginal relapse in stage I endometrial cancer, thereby potentially facilitating the selection of patients who may benefit from vaginal brachytherapy. METHODS The study population included 632 patients with stage I endometrial cancer managed with hysterectomy at our institution between 1984 and 1996. Median follow-up was 73 months; 122 patients (19%) received adjuvant radiotherapy. RESULTS Overall, 2.9% of the stage I cohort developed vaginal relapse at 5 years. Vaginal relapse was observed in 1.7% of patients who received radiotherapy and in 3.0% of those whose treatment did not include radiotherapy (P = 0.36). Cox regression analysis (including radiotherapy) identified only grade 3 differentiation (hazard ratio = 3.83, P = 0.007) as an independent predictor of vaginal relapse. Patients with a low-grade tumor had a 5-year vaginal relapse rate of 2%, compared with 7% for those with a grade 3 tumor. When only patients who did not receive adjuvant radiotherapy were considered, both grade 3 tumor and lymphovascular invasion were significant predictors of vaginal relapse (P < 0.05). When neither variable was present, 2% of patients experienced vaginal relapse at 5 years, compared with 11% when either 1 was present (P < 0.001). Depth of myometrial invasion was not a significant predictor of vaginal recurrence. CONCLUSION Histologic grade 3 tumor and lymphovascular invasion were the cogent predictors of vaginal relapse in our population. The cost and morbidity of vaginal brachytherapy should be balanced against the potential risk of vaginal relapse in this group of patients.
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Affiliation(s)
- Andrea Mariani
- Section of Gynecologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Mariani A, Dowdy SC, Keeney GL, Long HJ, Lesnick TG, Podratz KC. High-risk endometrial cancer subgroups: candidates for target-based adjuvant therapy. Gynecol Oncol 2004; 95:120-6. [PMID: 15385120 DOI: 10.1016/j.ygyno.2004.06.042] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To identify patients with endometrial cancer at risk for hematogenous, lymphatic, or peritoneal recurrence (or combinations of them) who might potentially benefit from target-based therapies. METHODS During a 13-year period, 915 patients had endometrial cancer managed with hysterectomy and standard adjuvant therapy. On the basis of our previous regression analyses, depth of myometrial invasion predicted the risk for hematogenous recurrence; positive lymph nodes and cervical stromal invasion predicted lymphatic recurrence; stage IV disease or combination of nonendometrioid histology, cervical stromal invasion, positive lymph nodes, and positive peritoneal cytology was predictive of peritoneal recurrence. Median follow-up was 66 months. RESULTS Applying the above criteria to the population of 915 patients, 24% were considered at risk for hematogenous recurrence, 18% for lymphatic recurrence, and 16% for peritoneal recurrence. The respective relapse rates at 5 years were 28% for patients who were at risk for hematogenous recurrence, 31% for lymphatic recurrence, and 42% for peritoneal recurrence. This contrasted with less than a 5% recurrence rate in the corresponding subgroups not at risk for relapse (P < 0.001). Collectively, of the 915 patients, 324 (35%) were considered at risk for recurrence in one or more of the above three sites. Overall, 89% of all recurrences were identified in this at-risk group. Importantly, 46% of the patients considered at risk subsequently had recurrence in one or more of the three sites, compared with only 2% of patients not at risk for relapse (P < 0.001). CONCLUSION Patients at risk for relapse had a 46% probability of experiencing recurrence within 5 years despite management with standard therapy. New target-based algorithms for the 35% of endometrial cancer patients deemed at risk should be incorporated in the development of future prospective multimodality clinical trials predicated on site(s) of recurrence.
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Affiliation(s)
- Andrea Mariani
- Section of Gynecologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Endometrial adenocarcinomas rank third as tumoral sites en France. The tumors are confined to the uterus in 80% of the cases. Brachytherapy has a large place in the therapeutic strategy. The gold standard treatment remains extrafascial hysterectomy with bilateral annexiectomy and bilateral internal iliac lymph node dissection. However, after surgery alone, the rate of locoregional relapses reaches 4-20%, which is reduced to 0-5% after postoperative brachytherapy of the vaginal cuff. This postoperative brachytherapy is delivered as outpatients treatment, by 3 or 4 fractions, at high dose rate. The uterovaginal preoperative brachytherapy remains well adapted to the tumors which involve the uterine cervix. Patients presenting a localized tumor but not operable for general reasons (< 10%) can be treated with success by exclusive irradiation, which associates a pelvic irradiation followed by an uterovaginal brachytherapy. A high local control of about 80-90% is obtained, a little lower than surgery, with a higher risk of late complications. Last but not least, local relapses in the vaginal cuff, or in the perimeatic area, can be treated by interstitial salvage brachytherapy, associated if possible with external beam irradiation. The local control is reached in half of the patients, but metastatic dissemination is frequent. We conclude that brachytherapy has a major role in the treatment of endometrial adenocarcinomas, in combination with surgery, or with external beam irradiation for not operable patients or in case of local relapses. It should use new technologies now available including computerized afterloaders and 3D dose calculation.
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Nag S, Yacoub S, Copeland LJ, Fowler JM. Interstitial brachytherapy for salvage treatment of vaginal recurrences in previously unirradiated endometrial cancer patients. Int J Radiat Oncol Biol Phys 2002; 54:1153-9. [PMID: 12419443 DOI: 10.1016/s0360-3016(02)03019-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To evaluate whether interstitial brachytherapy can effectively salvage vaginal recurrence from endometrial carcinoma. METHODS AND MATERIALS Between September 1989 and September 2000, 13 previously unirradiated patients (mean age 70 years) with isolated vaginal recurrences from endometrial adenocarcinoma were treated with interstitial low-dose-rate brachytherapy with or without additional external beam radiotherapy. Brachytherapy was delivered using a modified perineal Syed template loaded with (192)Ir. The central cylinder was loaded with high-activity (192)Ir (n = 12) or (137)Cs (n = 1). RESULTS The patients had initially presented with FIGO Stage I (n = 11) or III (n = 2) cancer. Vaginal recurrences were diagnosed at a mean interval of 27.5 months after hysterectomy (range 2-83). The patients were followed for a median of 60 months (range 15-105). Ten patients had recurrence at the vaginal apex and three had recurrence in the lower two-thirds of the vagina. The median time to recurrence was 22 months. The tumor size ranged from 1.5 to 6 cm (mean 2.2, median 2.5). Eleven of 13 patients received 45-50-Gy pelvic external beam radiotherapy, followed by a mean interstitial brachytherapy boost of 28.3 Gy (range 18-35). The 2 other patients received brachytherapy only of 40 Gy and 50 Gy, respectively. All tumors were locally controlled. Three (23%) of 13 patients had a relapse at distant sites (two in the paraaortic region and one in the liver). The overall 8-year actuarial disease-specific survival rate was 77%. Major (Grade 3 and 4) long-term morbidity occurred in 2 patients (15%) and included Grade 3 vaginal ulceration in 1 patient, and Grade 4 colovesical fistula requiring surgical intervention in 1 patient. Additional long-term morbidity included Grade 2 proctitis in 1 patient. CONCLUSION Interstitial brachytherapy with or without supplementary external beam radiotherapy can effectively salvage vaginal recurrence from endometrial cancer with very favorable local control and overall survival and acceptable morbidity.
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Affiliation(s)
- Subir Nag
- Division of Radiation Oncology, Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University, 300 W. Tenth Avenue, Columbus, OH 43210, USA.
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Hasbini A, Haie-Meder C, Morice P, Chirat E, Duvillard P, Lhommé C, Delapierre M, Gerbaulet A. Outcome after salvage radiotherapy (brachytherapy +/- external) in patients with a vaginal recurrence from endometrial carcinomas. Radiother Oncol 2002; 65:23-8. [PMID: 12413671 DOI: 10.1016/s0167-8140(02)00212-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The vagina is the site most commonly affected by loco-regional failure in endometrial carcinoma (EC). The aim of this study was to evaluate the efficacy of vaginal brachytherapy (BT) combined or not with whole pelvic external radiotherapy (RT) for the treatment of patients with vaginal recurrences from endometrial cancer. PATIENTS AND METHODS Between 1986 and 1999 25 women were treated at the Institut Gustave Roussy (IGR) for a vaginal relapse (VR) from EC. Patient characteristics were as follows: median age 65 years (range 43-84), histologic type: adenocarcinoma (21 patients); endometrioid carcinoma (three patients); adenoacanthoma (one patient); FIGO staging for initial disease: Ia, three; Ib, eight; Ic, four; II, seven; IIIa, two; IVa, one. The initial tumor was treated by surgery alone in 18 patients, or surgery combined with RT and/or BT in seven patients. A VR occurred in a median interval of 21 months (range 2-89); 10/25 (40%) occurred within the first year following initial treatment. The recurrence was exclusively in the vagina in 18 patients and was associated with parametrial and or nodal involvement in seven patients; it was localized in the upper 1/3 of the vagina in nine patients, in the upper 2/3 or the entire vagina in 11 patients or in the lower 1/3 in five patients. The largest tumor diameter ranged from 10 to 70 mm (median: 25 mm). The treatment of the VR included low-dose rate endocavitary BT in all cases: three patients received endocavitary BT alone, or it was associated with external RT in 22 patients or delivered after surgical removal of the lesion in nine patients. Seven patients were submitted to further irradiation combining endocavitary and interstitial BT. RESULTS Local control was achieved in 23 patients (92%). With a follow-up ranging from 4 to 154 months, 13 patients have died (ten due to metastasis, two of intercurrent disease and two due to local tumor progression) and ten patients are alive and disease free. The 3-year actuarial survival was 48%. Late radiation-related sequelae were observed in nine patients (mucous necrosis in one patient, moderate sclerosis in six patients) in an interval varying between 8 and 45 months. The majority of recurrences occurred in patients who had not previously received irradiation, which emphasizes the role of systematic prophylactic post-operative vaginal BT. Extra-vaginal extension (P < 0.001), the tumor size (P < 0.03) and the stage of initial disease (P < 0.01) appeared to have a significant impact on the prognosis. CONCLUSION BT combined with external RT is an efficient treatment for VR from EC even in previously irradiated patients. Poor survival remains related to metastatic dissemination.
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Affiliation(s)
- Ali Hasbini
- Department of Radiotherapy, Brachytherapy Service, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif, France
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Tewari KS, Cappuccini F, Puthawala AA, Kuo JV, Burger RA, Monk BJ, Manetta A, Berman ML, Disaia PJ, Nisar AM. Primary invasive carcinoma of the vagina: treatment with interstitial brachytherapy. Cancer 2001; 91:758-70. [PMID: 11241244 DOI: 10.1002/1097-0142(20010215)91:4<758::aid-cncr1062>3.0.co;2-u] [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: 11/06/2022]
Abstract
BACKGROUND Because primary carcinoma of the vagina comprises less than 2% of all gynecologic malignancies, the reported experience in the treatment of large numbers of patients is available only from a few major centers and most often encompasses a variety of differences in treatment selection and technique. The objective of this study was to assess the long term results of an interstitial iridium-192 afterloading implant technique using the Syed-Neblett dedicated vaginal plastic template. METHODS Patients who were treated from 1976 to 1997 were examined retrospectively. RESULTS Seventy-one patients underwent interstitial implantation with (n = 61 patients) or without external beam radiotherapy. The median age was 59 years (range, 16-86 years). Patients were staged according to the International Federation of Gynecology and Obstetrics system and included Stage I (n = 10 patients), Perez modification Stage IIA (n = 14 patients), Perez modification Stage IIB (n = 25 patients), Stage III (n = 15 patients), and Stage IV (n = 7 patients). Each implant delivered an approximately 20-gray (Gy) minimum tumor dose, with the total tumor dose reaching 80 Gy with integrated external beam radiotherapy. Local control was achieved in 53 patients (75%). The median follow-up was 66 months (range, 15-163 months), and the 2-year, 5-year, and 10-year actuarial disease free survival rates are 73%, 58%, and 58%, respectively. By stage, 5-year disease free survival rates included Stage I, 100% of patients; Stage IIA, 60% of patients; Stage IIB, 61% of patients; Stage III, 30% of patients; and Stage IV, 0% of patients. The factors disease stage and primary lesion size independently influenced the survival rates. Significant complications occurred in 9 patients (13%) and included necrosis (n = 4 patients), fistulae (n = 4 patients), and small bowel obstruction (n = 1 patient). CONCLUSIONS Interstitial irradiation can effect local control in the majority of patients with primary carcinoma of the vagina with acceptable morbidity. Long term cure is demonstrable in patients with Stage I-III disease.
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Affiliation(s)
- K S Tewari
- The Chao Family National Cancer Institute-Designated Comprehensive Cancer Center, University of California, Irvine Medical Center, Orange, California, USA
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