Time, dose and fractionation factor as an indicator of fibrosis of the abdominopelvic subcutaneous tissue

Evaluation of Late Toxicities of Patients with Carcinoma of the Cervix Treated with Radical Radiotherapy: An Audit from India

AIMS

To evaluate the incidence of, and factors affecting, late toxicities of women with carcinoma of the cervix treated with radical radiotherapy.

MATERIALS AND METHODS

Between 1996 and 2001, 1069 women with carcinoma of the cervix (stage I-IVA) were treated at our centre with external-beam radiotherapy (EBRT) and intra-cavitary radiotherapy (ICRT) (n = 871) or EBRT alone (n = 198). Median follow-up was 34 months. Median dose to point A was 81 Gy.

RESULTS

Five-year actuarial incidence of overall (all grades) and severe (grade 3/4) late toxicities in the rectum, bladder, small intestine and subcutaneous tissue were 12.3% and 1.1%, 11.2% and 1.2%, 9.2% and 0.2%, and 23.1% and 1.2%, respectively. Vaginal adhesions were seen in 29.6% of cases and stenosis in 33.9% of cases. On multivariate analysis, factors adversely affecting overall incidence of proctitis were anterior-posterior (AP) separation of patient more than 18 cm and presence of comorbid diseases. Presence of comorbid diseases was the only factor affecting the incidence of severe proctitis (grade 3/4). AP separation more than 18 cm adversely affected the incidence of cystitis, both overall and severe. Late toxicities (all grades) in small bowel were increased in subsets, like women younger than 50 years and women with comorbid diseases, but no factor emerged as significant for incidence of severe toxicities. Subcutaneous fibrosis was significantly higher in patients with AP separation over 18 cm, those treated by cobalt machines and those who received EBRT only. Severe subcutaneous fibrosis was influenced by the use of EBRT alone. Overall incidence of vaginal toxicity was higher in women whose overall treatment time (OTT) was shorter and in women who received ICRT. Vaginal stenosis was higher in elderly women and in women who received ICRT by low dose rate.

CONCLUSIONS

Even with telecobalt machines, impressive results with acceptable late toxicity can be achieved in the treatment of cancer of the cervix using an ideal combination of EBRT with ICRT.

Results of radiotherapy alone in the treatment of carcinoma of uterine cervix: a retrospective analysis of 1069 patients

Carcinoma of the uterine cervix is the most common malignancy affecting women in developing countries like India. This retrospective study was made to analyze our results of radiotherapy alone in the treatment of carcinoma cervix. Between January 1996 and December 2001, 1069 patients of carcinoma cervix were treated at our center with external beam radiotherapy (EBRT) and intracavitary radiotherapy (871) or EBRT alone (198). The median dose to point A was 81 Gy. Overall survival (OS), disease-free survival (DFS), and pelvic control at 5 years were 51.8%, 49.4%, and 63.9%, respectively. For the patients who could receive intracavitary radiotherapy (871), the OS, DFS, and pelvic control rates were 60.7%, 58.6%, and 73.5%, respectively. On multivariate analysis, bulk, overall treatment time (OTT) and response to EBRT were found to affect OS and DFS independently. Similarly, OTT, response to EBRT, stage, and age were the factors that influenced pelvic control. Incidence of severe late toxicities (grade 3/4) in the rectum, bladder, small intestine, and skin were 1.1%, 1.2%, 0.2%, and 1.2%, respectively. In developing countries like India, where chemoradiation can be afforded by a minority only, judicious use of radiotherapy still produces satisfactory results with acceptable toxicity. The addition of chemotherapy may be beneficial in patients with adverse prognostic factors.

Radiotherapy alone in the treatment of uterine cervix cancer with telecobalt and low-dose-rate brachytherapy: retrospective analysis of results and variables

PURPOSE

This retrospective analysis aims to report results and variables from patients with cervix cancer treated by radiation therapy alone with telecobalt and low-dose-rate brachytherapy (LDRB).

METHODS AND MATERIALS

Between September 1989 and September 1995, 190 patients with histologic diagnosis of cervix carcinoma were treated with telecobalt for external beam radiotherapy (EBR), followed by one or two insertions of LDRB. Stage distribution according to patients was the following: IB, 12; IIA, 4; IIB, 105; and IIIB, 69. Median dose of EBR at whole pelvis was 40 Gy, and median parametrial doses for Stages II and III patients were 50 Gy and 60 Gy, respectively. Median doses of LDRB at point A for patients treated with one and two insertions were 38 Gy and 50 Gy, respectively.

RESULTS

Median follow-up time was 70 months (range: 8-127 months). Overall survival, disease-free survival, and 5-year local control of patients at Stages I, II, and III were 83%, 78%, and 46%; 83%, 82%, and 49%; and 92%, 87%, and 58%, respectively. Overall incidence of late complications in the rectum, small bowel, and urinary tract was 15.3% (19/190), 4.2% (8/190), and 6.8% (13/190), respectively. The actuarial 5-year rectal, small bowel, and urinary incidence of late complications was 16.1%, 4.6%, and 7.6%, respectively. Clinical stage was the only significant variable for overall 5-year survival (p = 0.001), for disease-free survival (p = 0.001), and for local control (p = 0.001). Stage II patients more than 50 years old had better disease-free survival and local control at 5 years (p = 0.004). None of the analyzed variables influenced the actuarial 5-year incidence of late complications.

CONCLUSIONS

Results of this series suggest that the use of telecobalt equipment for EBR with doses up to 50 Gy at whole pelvis, prior to brachytherapy, is an acceptable technique for radiation therapy alone in the treatment of cervix cancer, especially in developing countries, including Brazil, where telecobalt machines still prevail.

Subcutaneous fibrosis after whole neck irradiation

PURPOSE

To identify the risk factors for moderate to severe subcutaneous fibrosis after whole neck irradiation.

MATERIALS AND METHODS

We analyzed 233 cases of patients who had undergone whole neck irradiation with 4-MV X-ray or 8-10-MeV electrons, or both, and had been followed with regard to their skin condition for at least 1 year. The prescribed dose to the whole neck ranged from 19.2 to 72.4 Gy (median 50). The skin-absorbed dose was specified as that at a depth of 4.1 mm (d4.1-mm(depth)), and a biologically equivalent dose (BED) of d4.1-mm(depth) was also estimated (BED(1.8) 4.1-mm(depth)).

RESULTS

Univariate analysis revealed that previous neck dissection, concurrent chemotherapy, corticosteroid administration as a part of chemotherapy, fractionation, and BED(1.8) 4.1-mm(depth) were significant prognostic variables. Multivariate analysis showed that BED(1.8) 4.1-mm(depth) and previous neck dissection were the only prognostic variables for moderate to severe subcutaneous fibrosis.

CONCLUSION

A high dose to a 4.1-mm depth of the skin and a history of neck dissection were identified as the predominant risk factors for moderate to severe subcutaneous fibrosis after whole neck irradiation. A subcutaneous dose should be considered in radiotherapy treatment planning involving the whole neck, especially in cases in which patients have undergone previous neck dissection.

Analysis of complications of cervix carcinoma treated by radiotherapy using the Franco-Italian glossary

We analysed the complications of 215 patients with uterine cervix cancer, treated by radiotherapy (RT) alone. It was done according to the rules of the Franco-Italian glossary, presented at the 7th ESTRO meeting, held in The Hague on September 1988. They were ranked by organ sites and by degrees of gravity. The analysis was done on the total number of complications and they were scored at the highest reached grade of gravity. Seventy one complications were found in 55 patients; they were studied by patient, degree of severity, time of onset, organ system and grade, time of onset and grade, time of onset and organ sites, stage and RT doses and brachytherapy volumes. The importance of the study of complications is stressed, particularly when treatment combines external RT and brachytherapy; some guidelines are given to avoid severe complications.

Complications of uterine cervix carcinoma treatments: the problem of a uniform classification

Ninety-six articles published in English, French and Italian between 1938 and 1986 have been examined in order to analyze the classifications and reporting methods used by different researchers. Specialty and nationality of authors, classifications used, organs, systems and anatomic sites considered, weight given to the most frequently encountered complications are studied. Fifty-nine papers make no use of classification of complications of any kind, neither by onset time, nor by severity, but simply describe the observed events. The remaining 37 papers use a classification based on varying criteria. Thirty-four authors use a classification by severity according to different criteria; four authors classify complications according to the treatment required. In the remaining 30 papers a true scale is used. A total of 22 classifications emerges from these papers; in eight cases a previously published classification is used. The weight assigned by different authors to specific complications has been compared. The following main points emerge from the analysis: about two authors out of three simply describe the observed complications; 30 rely on a true scale of severity, but 22 different grading systems are used. Most classifications do not cover all possible complications, both surgical and radiotherapeutic, but concentrate on those complications which are typically generated by author's therapeutic approach. Only three take into account complications related to different treatment modalities. The observation period is not standardized: published data derive from follow-up times spanning from some months to many years. Authors mainly focus their interest on gastrointestinal and/or urinary complications; other organs and systems are rarely considered.(ABSTRACT TRUNCATED AT 250 WORDS)