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Mutyala S, Patel G, Rivera AC, Brodin PN, Saigal K, Thawani N, Mehta KJ. High Dose Rate Brachytherapy for Inoperable Endometrial Cancer: a Case Series and Systematic Review of the Literature. Clin Oncol (R Coll Radiol) 2021; 33:e393-e402. [PMID: 34312020 DOI: 10.1016/j.clon.2021.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/14/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
Endometrial cancer is a common gynaecological cancer, is typically early stage and treated with surgery. For patients where surgery is difficult or dangerous, definitive radiation therapy is the next best option. This study included a single institution case series (step 1) and a systematic review of the literature (step 2). In step 1, all endometrial cancer cases that were treated with definitive image-guided brachytherapy at a single institution from 2008 to 2020 were retrospectively analysed. In step 2, a systematic review of Medline (PubMed) from 1975 to 2020 was carried out using the key words around endometrial cancer and brachytherapy, followed by a narrative synthesis. In total, in step 1, 31 cases were included in this study, stages I-IV, with 96.7% receiving external beam radiation. All patients received three fractions of 7.5 Gy or five fractions of 6 Gy high dose rate brachytherapy, with a median EQD2 of 75.55 (40-84.3). The 2-year Kaplan-Meier (KM) local control was 83.1% and the 2-year KM overall survival was 77.4%. There was no late toxicity ≥grade 3. In step 2, 19 articles were included in the final analysis, with between six and 280 patients. The local control ranged from 70 to 100%, with low toxicity. Definitive radiation therapy with image-guided brachytherapy seems to have good local control with low toxicity for patients who are poor surgical candidates.
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Affiliation(s)
- S Mutyala
- University of Arizona College of Medicine - Phoenix, Arizona Oncology Associates, Phoenix, Arizona, USA.
| | - G Patel
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York, USA
| | - A C Rivera
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York, USA
| | - P N Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York, USA
| | - K Saigal
- Florida Cancer Specialists and Research Institute, Sarasota Memorial, Brian D. Jellison Cancer Center, Sarasota, Florida, USA
| | - N Thawani
- University of Arizona College of Medicine - Phoenix, Creighton University School of Medicine, Dignity Health Cancer Institute, Phoenix, Arizona, USA
| | - K J Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York, USA
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Wang L, Wang X, Zhang Q, Ran J, Geng Y, Feng S, Li C, Zhao X. Is there a role for carbon therapy in the treatment of gynecological carcinomas? A systematic review. Future Oncol 2019; 15:3081-3095. [PMID: 31426679 DOI: 10.2217/fon-2019-0187] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This Systematic Review summarizes the literatures of clinical trials on the efficacy and safety of carbon ion therapy for gynecological carcinomas. The protocol is detailed in the online PROSPERO database, registration no. CRD42019121424, and a final set of eight studies were included. In the treatment of cervical carcinomas, both carbon ion therapy alone and carbon ion therapy concurrent chemotherapy have presented good efficacy. Besides, the efficacy of inoperable endometrial carcinomas and gynecological melanoma are similar to that of surgical treatment. In terms of safety, gastrointestinal and genitourinary toxicities are low and could be controlled by limiting the volume and dose of intestinal tract and bladder. Carbon ion radiotherapy could be considered a safe, effective and feasible therapy for gynecological carcinomas.
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Affiliation(s)
- Lina Wang
- Radiotherapy Department, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu, PR China.,The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Xiaohu Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China.,Gansu Provincial Cancer Hospital, Lanzhou 730000, Gansu, PR China
| | - Qiuning Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China.,Gansu Provincial Cancer Hospital, Lanzhou 730000, Gansu, PR China
| | - Juntao Ran
- Radiotherapy Department, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Yichao Geng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Shuangwu Feng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Chengcheng Li
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Xueshan Zhao
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
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Staples JN, Rauh L, Peach MS, Baker WD, Modesitt SC. Endometrial cancer in an increasingly obese population: Exploring alternative options when surgery may not cut it. Gynecol Oncol Rep 2018; 25:30-34. [PMID: 29977988 PMCID: PMC6030024 DOI: 10.1016/j.gore.2018.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/19/2018] [Accepted: 04/21/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The study objectives were to describe outcomes of obese patients with early endometrial cancer following primary non-surgical treatment, assess predictors of response, and estimate the increased surgical risk for these women. METHODS Retrospective chart review identified women with early stage endometrial cancer at a single institution with BMI ≥ 30 kg/m2 who did not undergo surgery as primary treatment modality due to obesity and medical co-morbidities. Clinicopathologic factors were abstracted, characteristics of responders vs. non-responders compared and the National Surgical Quality Improvement Program (NSQIP) surgical risk calculator utilized to quantify surgical risks. RESULTS Fifty-one patients were identified, with a mean BMI of 49.0 kg/m2. The NSQIP calculator predicted a significantly higher complication rate for our cohort compared to the expected average risk for hysterectomy (18.8% vs 7.2%, p < .0001). The majority of patients were treated with radiation alone (49%), followed by hormone therapy (45.1%). Response rates were 38.1% for women treated with hormones and 63.6% in the radiation group (p = .063). No significant differences were identified between responders and non-responders with regard to NSQIP scores, BMI, co-morbidities or age. Among those with persistent or progressive disease, 87.5% responded to secondary treatment. Only one death was from cancer progression. Two individuals died following treatment complications (one surgical, one chemotherapy); the remaining twelve deaths were due to pre-existing co-morbidities. CONCLUSIONS Hormone and radiation therapy are both viable options for obese patients deemed to have too significant risk of surgical complications. Pursuing surgical intervention in this population may do more harm than good.
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Affiliation(s)
- Jeanine N. Staples
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, United States
| | - Lisa Rauh
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, United States
| | - M. Sean Peach
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, United States
| | - William D. Baker
- Novant Health Oncology Specialists, Winston-Salem, NC, United States
| | - Susan C. Modesitt
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, United States
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Irie D, Okonogi N, Wakatsuki M, Kato S, Ohno T, Karasawa K, Kiyohara H, Kobayashi D, Tsuji H, Nakano T, Kamada T, Shozu M. Carbon-ion radiotherapy for inoperable endometrial carcinoma. JOURNAL OF RADIATION RESEARCH 2018; 59:309-315. [PMID: 29528414 PMCID: PMC5967462 DOI: 10.1093/jrr/rry003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/18/2017] [Indexed: 09/29/2023]
Abstract
This is a pooled analysis to evaluate the toxicity and efficacy of carbon-ion radiotherapy (C-ion RT) for inoperable endometrial carcinoma. Eligible patients had previously untreated Stage I-III endometrial carcinoma without para-aortic lymph node metastasis. Total dose to the tumor was 62.4-74.4 Gy [relative biological effectiveness (RBE)] in 20 fractions, and the dose to the gastrointestinal tract was limited to <60 Gy (RBE). Intracavitary brachytherapy was not combined in the present study. Fourteen patients with endometrial carcinoma were analyzed. Ten of the 14 patients were judged medically inoperable, and the others refused surgery. The numbers of patients with Stage I, II and III disease were 1, 9 and 4, respectively. Tumor size was 3.8-13.8 cm in maximum diameter. Median follow-up periods for all patients and surviving patients were 50 months (range, 12-218 months) and 78 months (range, 23-218 months), respectively. Two of three patients receiving 62.4-64.8 Gy (RBE) had local recurrence whereas none of 11 patients receiving 68.0 Gy (RBE) or more had local recurrence. Three patients developed distant metastases and one of them also had local recurrence. The 5-year local control, progression-free survival, overall survival, and cause-specific survival rates were 86%, 64%, 68% and 73%, respectively. No patient developed Grade 3 or higher acute or late toxicity. The present study showed that C-ion RT alone could be a safe and curative treatment modality for inoperable endometrial carcinoma.
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Affiliation(s)
- Daisuke Irie
- Hospital, National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, 263-8555, Japan
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi-shi, Gunma, 371-8511, Japan
| | - Noriyuki Okonogi
- Hospital, National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, 263-8555, Japan
| | - Masaru Wakatsuki
- Hospital, National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, 263-8555, Japan
- Department of Radiology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi-shi, Gunma, 371-8511, Japan
| | - Kumiko Karasawa
- Department of Radiology, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroki Kiyohara
- Department of Radiology, Maebashi Red Cross Hospital, 3-21-36 Asahi-cho, Maebashi-shi, Gunma, 371-0014, Japan
| | - Daijiro Kobayashi
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi-shi, Gunma, 371-8511, Japan
| | - Hiroshi Tsuji
- Hospital, National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, 263-8555, Japan
| | - Takashi Nakano
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi-shi, Gunma, 371-8511, Japan
| | - Tadashi Kamada
- Hospital, National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, 263-8555, Japan
| | - Makio Shozu
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Ciba, 260-8670, Japan
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Value of endometrial thickness assessed by transvaginal ultrasound for the prediction of endometrial cancer in patients with postmenopausal bleeding. Arch Gynecol Obstet 2017. [PMID: 28634754 DOI: 10.1007/s00404-017-4439-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Histological confirmation of endometrial cancer by dilatation/curettage (D/C) in women with postmenopausal bleeding (PMB) can be challenging due to anesthesiological and/or surgical risks. Thus, less invasive methods for diagnostics are required to identify patients with minimal risk for endometrial cancer (EC) to avoid unnecessary surgical intervention. The objective of this single-center cohort study was to assess the diagnostic validity of transvaginal ultrasound (TVUS) measurements of endometrial thickness (ET) in patients with PMB for the detection of EC. METHODS A retrospective analysis of data from patients presenting between January 2005 and August 2014 at the Department of Obstetrics and Gynecology, University Hospital Ulm, Germany, with PMB and subsequent D/C was performed. Complete data with TVUS documentation of ET and histological results of tissue samples were available from 254 patients. In addition, data on age, body mass index (BMI), ASA-score, diabetes, hypertension, and hematological laboratory values (for a smaller subsample) were recorded. To identify independent risk factors, a multivariate logistic regression with endometrial cancer as binary response variable (yes/no) was performed. Diagnostic efficacy data for different ET cutoff points (≤1 to ≤26 mm) were obtained by a receiver operator characteristic (ROC) curve analysis. RESULTS The multivariate logistic regression revealed a significant independent predictive value for age and ET. However, none of the analyzed ET cutoff points showed optimal diagnostic validity, as all cutoff points with sensitivity rates above 90% (≤1 to ≤5 mm) had false positive rates of 70% and higher. CONCLUSIONS There is no ET cutoff point that provides good diagnostic accuracy and/or reliably excludes the presence of endometrial cancer in patients with PMB. Thus, our data analysis supports the actual German approach of histological evaluation of any PMB to confirm or exclude EC.
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Beriwal S, Kim H, Heron DE, Selvaraj R. Comparison of 2D vs. 3D Dosimetry for Rotte ‘Y’ Applicator High Dose Rate Brachytherapy for Medically Inoperable Endometrial Cancer. Technol Cancer Res Treat 2016; 5:521-7. [PMID: 16981795 DOI: 10.1177/153303460600500509] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of our research is to compare CT-based volumetric calculations and International Commission on Radiation Units and Measurements (ICRU) reference-point estimates of radiation doses to the target volume, bladder, rectum, and sigmoid colon in patients with carcinoma of the endometrium treated with high dose rate intracavitary Rotte ‘Y’ applicator brachytherapy (HDRB). Eleven patients with cancer of the endometrium were treated with CT-compatible HDR intracavitary Rotte ‘Y’ applicators (Nucletron) and underwent post-implant pelvic CT scans with applicators in place. All patients were treated using orthogonal radiography-based planning. The dose was prescribed to uterine point (a point located 2 cm below the center of a line drawn between the tips of the two ends of the Rotte applicator extending laterally from the tandem by half the maximum uterine width), Point A, and 0.5 cm depth along the upper 3 cm vagina. CT-images were transferred to the PLATO treatment planning system version 14.2.6 and retrospectively planned for volumetric calculations. The clinical target volume (CTV) included the entire uterus, cervix, and upper 3 cm of vagina. The volumes of organs at risk (OAR) were digitized. Dwell positions were identified and registered in both the uterine tandem for each patient. For those receiving HDRB alone, the prescribed dose was 7 Gy x 5 fractions. Patients who were treated following external beam radiation therapy (EBRT) received 4Gy x 5 fractions. The interfraction interval was 6–8 hours. The DVHs were computed for the CTV, bladder, rectum, and sigmoid colon. To compare doses of OARs, 1.0 cc, 2.0 cc, and 5.0 cc volumes receiving the highest dose were calculated from DVHs. 3D optimization was done to improve target coverage and decrease dose to critical organs and compared with the 2D orthogonal radiograph-based plan. The mean of percentage of prescribed dose ± S.D to 1 cc, 2 cc, and 5 cc of the OARs of interest were as follows: Rectum 44 ± 21%, 39 ± 18%, and 33 ± 15%; bladder 104 ± 36%, 91 ± 31%, and 73.9 ± 24%; and sigmoid 124 ± 35%, 109 ± 30%, and 89 ± 25%, respectively. The corresponding dose to ICRU 38 bladder and rectal points were 98 ± 55% and 50.5 ± 32%, respectively. The mean dose to uterine point and point A were 99 ± 1.7% and 98 ± 3%, respectively. The mean CTV volume was 160 ± 89 cc with the percentage of volume getting 100% and 90% of the dose being 62 ± 12% and 68 ± 12% with 2D plan versus 57 ± 8% and 67 ± 8.9% with 3D plan. The dose to critical organs were reduced with 3D optimization for rectum, bladder, and sigmoid by 5.6% (p = 0.04), 20.6% (p = 0.02), and 26.8% (p = 0.005), respectively. Compared to the 3-D volume dose, the prescription points overestimated the dose to the target volume. The under-dosing was because of inability of two channel applicator to cover volumes in the region of the cervix and vagina. The dose to sigmoid colon was high and attention should be given to the sigmoid dose at the time of treatment planning. 3D planning helped in reducing the dose to the critical organs without compromising target coverage. Correlations with outcome are needed to better define the role of 3D dosimetry in treatment planning.
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Affiliation(s)
- Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Zhou Q, Zhao KW, Xiong YL, Chen S, Xu WJ, Lei X. Clinical assessment of 252Californium neutron intracavitary brachytherapy using a two-channel Y applicator combined with external beam radiotherapy for endometrial cancer. Clinics (Sao Paulo) 2016; 71:10-6. [PMID: 26872078 PMCID: PMC4732408 DOI: 10.6061/clinics/2016(01)03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/09/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the efficacy of 252Californium neutron intracavitary brachytherapy using a two-channel Y applicator combined with external beam radiotherapy for the treatment of endometrial cancer. METHODS Thirty-one patients with stage I-III endometrial cancer were recruited for this study. The stage I patients received only 252Californium neutron intracavitary brachytherapy with a two-channel applicator. The stage II and III patients received both 252Californium neutron intracavitary brachytherapy using a two-channel applicator and parallel-opposed whole pelvic radiotherapy. RESULTS The five-year local control rate was 80.6% (25/31), the overall survival rate was 51.6% (16/31), and the disease-free survival rate was 54.8% (17/31). The incidence of serious late complications was 12.9% (4/31). CONCLUSIONS 252Californium neutron intracavitary brachytherapy using a two-channel applicator combined with external beam radiotherapy was effective for treating endometrial cancer and the incidence of serious late complications related to this combination was within an acceptable range.
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Affiliation(s)
| | | | | | | | | | - Xin Lei
- corresponding author E-mail:
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8
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Medically inoperable endometrial cancer in patients with a high body mass index (BMI): Patterns of failure after 3-D image-based high dose rate (HDR) brachytherapy. Radiother Oncol 2016; 118:167-72. [DOI: 10.1016/j.radonc.2015.12.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 11/21/2022]
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Murthy A, Manur J, Ponni A, Koushik K, Alva R, Somashekar M, Kannan R, Harjani R. A case of endometrial carcinoma with age related hyperkyphosis treated with definitive radiotherapy. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2014. [DOI: 10.14319/ijcto.0301.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Gill BS, Kim H, Houser C, Olsen A, Kelley J, Edwards RP, Comerci J, Sukumvanich P, Olawaiye AB, Huang M, Courtney-Brooks M, Beriwal S. Image-based three-dimensional conformal brachytherapy for medically inoperable endometrial carcinoma. Brachytherapy 2014; 13:542-7. [DOI: 10.1016/j.brachy.2014.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/27/2014] [Accepted: 07/08/2014] [Indexed: 10/24/2022]
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Dankulchai P, Petsuksiri J, Chansilpa Y, Hoskin PJ. Image-guided high-dose-rate brachytherapy in inoperable endometrial cancer. Br J Radiol 2014; 87:20140018. [PMID: 24807067 DOI: 10.1259/bjr.20140018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Inoperable endometrial cancer may be treated with curative aim using radical radiotherapy alone. The radiation techniques are external beam radiotherapy (EBRT) alone, EBRT plus brachytherapy and brachytherapy alone. Recently, high-dose-rate brachytherapy has been used instead of low-dose-rate brachytherapy. Image-guided brachytherapy enables sufficient coverage of tumour and reduction of dose to the organs at risk, thus increasing the therapeutic ratio of treatment. Local control rates with three-dimensional brachytherapy appear better than with conventional techniques (about 90-100% and 70-90%, respectively).
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Affiliation(s)
- P Dankulchai
- 1 Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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12
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Cost-Utility of Routine Endometrial Evaluation Before Le Fort Colpocleisis. Female Pelvic Med Reconstr Surg 2014; 20:168-73. [DOI: 10.1097/spv.0000000000000043] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Primary brachytherapy as a radical treatment for endometrial carcinoma. J Contemp Brachytherapy 2014; 6:106-12. [PMID: 24790629 PMCID: PMC4003435 DOI: 10.5114/jcb.2014.42028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 03/28/2014] [Accepted: 03/28/2014] [Indexed: 11/29/2022] Open
Abstract
Surgery is the primary treatment for endometrial cancer, with radiation therapy having an established place in the adjuvant treatment setting. However, there is a population of patients with endometrial cancer who may not be suitable for surgery and primary radiation therapy as a treatment option. This article describes the place of radiotherapy in the management of endometrial cancer and describes the author's own experiences with primary brachytherapy in those patients who are unsuitable for surgery.
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14
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Use of image-guided stereotactic body radiation therapy in lieu of intracavitary brachytherapy for the treatment of inoperable endometrial neoplasia. Int J Radiat Oncol Biol Phys 2012; 85:129-35. [PMID: 22503523 DOI: 10.1016/j.ijrobp.2012.02.058] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/27/2012] [Accepted: 02/28/2012] [Indexed: 11/20/2022]
Abstract
PURPOSE Retrospective analysis of patients with invasive endometrial neoplasia who were treated with external beam radiation therapy followed by stereotactic body radiation therapy (SBRT) boost because of the inability to undergo surgery or brachytherapy. METHODS AND MATERIALS We identified 11 women with stage I-III endometrial cancer with a median age of 78 years that were not candidates for hysterectomy or intracavitary brachytherapy secondary to comorbidities (91%) or refusal (9%). Eight patients were American Joint Committee on Cancer (AJCC) stage I (3 stage IA, 5 stage IB), and 3 patients were AJCC stage III. Patients were treated to a median of 4500 cGy at 180 cGy per fraction followed by SBRT boost (600 cGy per fraction×5). RESULTS The most common side effect was acute grade 1 gastrointestinal toxicity in 73% of patients, with no late toxicities observed. With a median follow-up of 10 months since SBRT, 5 patients (45%) experienced locoregional disease progression, with 3 patients (27%) succumbing to their malignancy. At 12 and 18 months from SBRT, the overall freedom from progression was 68% and 41%, respectively. Overall freedom from progression (FFP) was 100% for all patients with AJCC stage IA endometrial carcinoma, whereas it was 33% for stage IB at 18 months. The overall FFP was 100% for International Federation of Obstetrics and Gynecology grade 1 disease. The estimated overall survival was 57% at 18 months from diagnosis. CONCLUSION In this study, SBRT boost to the intact uterus was feasible, with encouragingly low rates of acute and late toxicity, and favorable disease control in patients with early-stage disease. Additional studies are needed to provide better insight into the best management of these clinically challenging cases.
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Podzielinski I, Randall ME, Breheny PJ, Escobar PF, Cohn DE, Quick AM, Chino JP, Lopez-Acevedo M, Seitz JL, Zook JE, Seamon LG. Primary radiation therapy for medically inoperable patients with clinical stage I and II endometrial carcinoma. Gynecol Oncol 2012; 124:36-41. [DOI: 10.1016/j.ygyno.2011.09.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 08/31/2011] [Accepted: 09/17/2011] [Indexed: 11/16/2022]
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Dewdney SB, Mutch DG. Evidence-based review of the utility of radiation therapy in the treatment of endometrial cancer. ACTA ACUST UNITED AC 2011; 6:695-703; quiz 704. [PMID: 20887169 DOI: 10.2217/whe.10.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Endometrial cancer is the most common cancer of the female genital tract in the USA and usually presents at an early stage. Most women are cured with surgery, however, some patients may require adjuvant therapy including radiation and/or chemotherapy. Risk factors determine the need for adjuvant treatment and, based on these risk factors, patients are categorized as being at low, intermediate or high risk for recurrence. In this article we will review the best level of evidence available for the use of radiation therapy within each risk stratum. The most controversy and debate is associated with patients stratified to the intermediate-risk group.
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Affiliation(s)
- S B Dewdney
- Department of Obstetrics & Gynecology, Washington University School of Medicine and Siteman Cancer Center, St Louis, MO 63110, USA.
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Wegner RE, Beriwal S, Heron DE, Richard SD, Kelly JL, Edwards RP, Sukumvanich P, Zorn KK, Krivak TC. Definitive radiation therapy for endometrial cancer in medically inoperable elderly patients. Brachytherapy 2010; 9:260-5. [DOI: 10.1016/j.brachy.2009.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 08/13/2009] [Accepted: 08/19/2009] [Indexed: 11/25/2022]
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Inciura A, Atkocius V, Juozaityte E, Vaitkiene D. Long-term results of high-dose-rate brachytherapy and external-beam radiotherapy in the primary treatment of endometrial cancer. JOURNAL OF RADIATION RESEARCH 2010; 51:675-681. [PMID: 21116100 DOI: 10.1269/jrr.10080] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In this report we update our long-term follow-up results of the prospective study whose aim was to evaluate the efficacy of high-dose-rate (HDR) brachytherapy in combination with external-beam radiotherapy (EBRT) in the treatment of medically inoperable endometrial cancer. Between 1995 and 1998, 29 patients with stages I-III medically inoperable carcinoma of endometrium were treated with definitive irradiation. All patients underwent combined intracavitary HDR brachytherapy and EBRT. The EBRT dose was 50 Gy with midline shield from 16 Gy. The HDR brachytherapy dose was 50 Gy, delivered in 5 fractions in a weekly schedule. Overall survival (OS) at 5 and 10 years was 48.3% and 20.7%, respectively. Disease-specific survival (DSS) at 5 and 10 years was 73.5% and 67.9%, respectively. The 10-year DSS rate was 73.5% for all stages, 85.7% for Stage I disease, 71.4% for Stage II, and 16.7% for stage III disease. Late Grade 1-2 radiation complications were observed in 4 patients (13.8%). Our long-term follow-up confirms that HDR brachytherapy with EBRT appears to be an effective and safe treatment for stage I and II medically inoperable endometrial cancer.
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Shenfield CB, Pearcey RG, Ghosh S, Dundas GS. The management of inoperable Stage I endometrial cancer using intracavitary brachytherapy alone: A 20-year institutional review. Brachytherapy 2009; 8:278-83. [DOI: 10.1016/j.brachy.2008.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 10/30/2008] [Accepted: 11/05/2008] [Indexed: 01/23/2023]
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High-Dose-Rate Rotte “Y” Applicator Brachytherapy for Definitive Treatment of Medically Inoperable Endometrial Cancer: 10-Year Results. Int J Radiat Oncol Biol Phys 2008; 71:779-83. [DOI: 10.1016/j.ijrobp.2007.10.026] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 10/05/2007] [Accepted: 10/19/2007] [Indexed: 11/17/2022]
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Definitive radiotherapy for medically inoperable early-stage serous and clear cell uterine carcinoma. ACTA ACUST UNITED AC 2007; 25:536-40. [PMID: 18085405 DOI: 10.1007/s11604-007-0173-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 07/06/2007] [Indexed: 10/22/2022]
Abstract
High-risk, early-stage endometrial cancer is optimally treated by hysterectomy followed by adjuvant radiotherapy. In 1%-9% of cases, the patient is medically unfit or personally unwilling to undergo primary surgery, and definitive radiotherapy may be offered as an alternative definitive therapy. Although several series have reported excellent intrauterine control and disease-specific survival for endometrioid histology, few outcome data are available for patients with serous or clear cell histology treated with radiotherapy alone. We herein describe one case each of early-stage, medically inoperable serous/clear cell histology endometrial cancer treated with definitive radiotherapy. Treatment was well tolerated by both patients, and neither patient required a treatment break. Acute toxicity consisted of self-limited cystitis in one patient. One patient was without evidence of disease progression at 54 months after radiotherapy.
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Moore KN, Lanneau GS, Smith C, Lanneau M, Walker JL, Gold MA, Scott McMeekin D. Pathologic findings and outcomes for octogenarians presenting with uterine malignancy. Gynecol Oncol 2007; 106:572-8. [PMID: 17618678 DOI: 10.1016/j.ygyno.2007.05.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Revised: 05/09/2007] [Accepted: 05/14/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We evaluated prognostic, demographic and outcome data for patients>80 years old with uterine cancer (UC). METHODS A retrospective review of clinical records was performed. Categorical data were compared using Fisher's exact test and Kaplan-Meier for survival data. RESULTS Sixty-five patients were identified with a mean age of 84 and BMI 27. Sixty-five percent of patients had medical co-morbidities. Forty-two (65%) were Stage I; 10 (15%) were Stage II; 8 (12%) were Stage III; and 5 (8%) were Stage IV. Stage I patients included those identified via hysterectomy with lymph nodes (LND) (30) or clinical impression (12). Comparing clinically Stage I UC to those with LND, the clinical group was older (86 vs. 83; p=0.01) and tended to have more medical co-morbidity (89% vs. 63%; p=0.14). Two-year overall survival (OS) among unstaged vs. staged patients was 62% vs. 77%; p=0.11. Among staged patients with Stage I UC, 21 (70%) met high intermediate risk (HIR) criteria per GOG 99 and 90% received no adjuvant therapy. Three patients (16%) recurred with 1 (5%) locoregional recurrence. Two-year OS is 77%. CONCLUSION Elderly patients with UC have features associated with extrauterine spread. Both clinically and surgically staged Stage I patients had excellent OS at 2 years despite no adjuvant therapy. Prevalent medical co-morbidities may impact survival more than recurrence risk. The 23% recurrence rate among HIR patients in GOG 99 was not observed in our data, suggesting that observation for elderly Stage I patients is acceptable.
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Affiliation(s)
- Kathleen N Moore
- University of Oklahoma Division of Gynecologic Oncology, 920 SL Young Blvd., Oklahoma City, OK 73103, USA.
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Weitmann HD, Pötter R, Waldhäusl C, Nechvile E, Kirisits C, Knocke TH. Pilot study in the treatment of endometrial carcinoma with 3D image–based high-dose-rate brachytherapy using modified Heyman packing: Clinical experience and dose–volume histogram analysis. Int J Radiat Oncol Biol Phys 2005; 62:468-78. [PMID: 15890589 DOI: 10.1016/j.ijrobp.2004.10.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2004] [Revised: 10/04/2004] [Accepted: 10/08/2004] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to evaluate dose distribution within uterus (clinical target volume [CTV]) and tumor (gross tumor volume [GTV]) and the resulting clinical outcome based on systematic three-dimensional treatment planning with dose-volume adaptation. Dose-volume assessment and adaptation in organs at risk and its impact on side effects were investigated in parallel. METHODS AND MATERIALS Sixteen patients with either locally confined endometrial carcinoma (n = 15) or adenocarcinoma of uterus and ovaries after bilateral salpingo-oophorectomy (n = 1) were included. Heyman packing was performed with mean 11 Norman-Simon applicators (3-18). Three-dimensional treatment planning based on computed tomography (n = 29) or magnetic resonance imaging (n = 18) was done in all patients with contouring of CTV, GTV, and organs at risk. Dose-volume adaptation was achieved by dwell location and time variation (intensity modulation). Twelve patients treated with curative intent received five to seven fractions of high-dose-rate brachytherapy (7 Gy per fraction) corresponding to a total dose of 60 Gy (2 Gy per fraction and alpha/beta of 10 Gy) to the CTV. Four patients had additional external beam radiotherapy (range, 10-40 Gy). One patient had salvage brachytherapy and 3 patients were treated with palliative intent. A dose-volume histogram analysis was performed in all patients. On average, 68% of the CTV and 92% of the GTV were encompassed by the 60 Gy reference volume. Median minimum dose to 90% of CTV and GTV (D90) was 35.3 Gy and 74 Gy, respectively. RESULTS All patients treated with curative intent had complete remission (12/12). After a median follow-up of 47 months, 5 patients are alive without tumor. Seven patients died without tumor from intercurrent disease after median 22 months. The patient with salvage treatment had a second local recurrence after 27 months and died of endometrial carcinoma after 57 months. In patients treated with palliative intent, symptom relief was achieved. No severe acute and late side effects (Grade 3/4) were observed. CONCLUSIONS Sectional image-based three-dimensional treatment planning on computed tomography and magnetic resonance imaging is feasible in definitive brachytherapy of endometrial carcinoma and enables by the use of dwell time and location adaptation a sufficient coverage of GTV and major parts of CTV. Local control in this limited number of patients is excellent and rate of side effects minimal.
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Affiliation(s)
- Hajo Dirk Weitmann
- Department of Radiotherapy and Radiobiology, Medical University of Vienna, General Hospital of Vienna, Wien, Austria.
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Kim RY, Falkenberg E, Pareek P. Image-based intracavitary brachytherapy in the treatment of inoperable uterine cancer: Individual dose specification at specific anatomical sites. Brachytherapy 2005; 4:286-90. [PMID: 16344259 DOI: 10.1016/j.brachy.2005.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE With advances in imaging studies, dose specification for uterine cancer can be defined at specific anatomical sites such as the myometrium or the serosal surface rather than at arbitrary points or milligram-hours. This report presents our experience with image-based brachytherapy for inoperable uterine cancer. METHODS AND MATERIALS Eight patients with organ-confined uterine cancer (2 Stage I GI, 3 Stage I G2, 3 Stage I G3) underwent definitive radiation therapy because of poor medical condition. All the patients underwent a CT or MRI scan of the pelvis before intracavitary application. Based on the size of the uterine cavity, a single-channel intrauterine applicator was selected for a small uterus, and a multiple-channel intrauterine applicator was used for a large uterus. A CT (n=5) or MRI (n=3) scan of the pelvis was performed with the applicator in place in addition to orthogonal pelvic films. Individualized dose specification was 75Gy to the midmyometrium and limited to 50Gy to the serosal surface of the uterus based on imaging information. RESULTS Four patients with Stage I G1-2 disease had intracavitary brachytherapy alone. Four patients with Stage I G2-3 disease were treated with a combination of external pelvic radiation and intracavitary brachytherapy. Six patients had low-dose-rate brachytherapy, and 2 patients had high-dose-rate brachytherapy. Five patients had single-channel intrauterine brachytherapy, and 3 patients had multiple-channel brachytherapy. Based on the measurements of the uterine wall thickness by the imaging studies, the dose specification was prescribed to 1.5 cm lateral to the central axis of the uterus in 4 patients, 2.0 cm in 3 patients, and 2.5 cm in 1 patient. The medium followup time after radiation treatment was 38 months. Six patients are alive without evidence of disease, and 2 patients died of other causes. All patients had local control without major side effects. CONCLUSIONS Image-based brachytherapy based on individualized dose specification at specific anatomical sites can be done easily and provides excellent local control for inoperable uterine cancer.
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Affiliation(s)
- Robert Y Kim
- Department of Radiation Oncology, Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Touboul E, Belkacémi Y, Buffat L, Deniaud-Alexandre E, Lefranc J, Lhuillier P, Uzan S, Jannet D, Uzan M, Antoine M, Ginesty C, Ganansia V, Jamali M, Milliez J, Blondon J, Schlienger M. Adénocarcinome de l’endomètre traité par association radiochirurgicale : à propos de 437 cas. Cancer Radiother 2001. [DOI: 10.1016/s1278-3218(01)00113-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Touboul E, Belkacémi Y, Buffat L, Deniaud-Alexandre E, Lefranc JP, Lhuillier P, Uzan S, Jannet D, Uzan M, Antoine M, Huart J, Ganansia V, Milliez J, Blondon J, Housset M, Schlienger M. Adenocarcinoma of the endometrium treated with combined irradiation and surgery: study of 437 patients. Int J Radiat Oncol Biol Phys 2001; 50:81-97. [PMID: 11316550 DOI: 10.1016/s0360-3016(00)01571-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas. METHODS AND MATERIALS Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system (225 Stage IB, 107 Stage IC, 4 Stage IIA, 35 Stage IIB, 30 Stage IIIA, 6 Stage IIIB, and 30 Stage IIIC), underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of adjuvant RT was not randomized and depended on the usual practices of the surgical teams. Seventy-nine pts (Group I) received preoperative low-dose-rate uterovaginal brachytherapy (mean dose [MD]: 57 Gy). Three hundred fifty-eight pts (Group II) received postoperative RT. One hundred ninety-six pts received low-dose-rate vaginal brachytherapy alone (MD: 50 Gy). One hundred fifty-eight pts had external beam pelvic RT (MD: 46 Gy) followed by low-dose-rate vaginal brachytherapy (MD: 17 Gy). Four pts had external beam pelvic RT alone (MD: 47 Gy). The mean follow-up from the beginning of treatment was 128 months. RESULTS The 10-year disease-free survival rate was 86%. From 57 recurrences, only 12 were isolated locoregional recurrences. The independent factors decreasing the probability of disease-free survival were as follows: histologic type (clear-cell carcinoma, p = 0.038), largest histologic tumor diameter >3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.005), and 1988 FIGO staging system (p = 9.10(-8)). In Group II, the addition of external beam pelvic RT did not seem to independently improve vaginal or pelvic control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were stage FIGO (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for Grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. External beam pelvic RT independently increased the rate for Grade 3 and 4 late complication (RR: 5.6, p = 0.0096). CONCLUSION Postoperative external beam pelvic RT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in subgroup of "intermediate-risk" patients (Stage IA Grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with Stage III tumor are not satisfactory.
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Affiliation(s)
- E Touboul
- Department of Radiation Oncology, Centre des Tumeurs, Tenon Hospital, 4 rue de la Chine, 75020 Paris, France
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Outwater EK. Invited Commentary. Radiographics 1999. [DOI: 10.1148/radiographics.19.4.g99jl06946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nguyen TV, Petereit DG. High-dose-rate brachytherapy for medically inoperable stage I endometrial cancer. Gynecol Oncol 1998; 71:196-203. [PMID: 9826460 DOI: 10.1006/gyno.1998.5148] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The objective of this study was to determine the efficacy of high-dose-rate (HDR) brachytherapy in 36 medically inoperable patients with stage I endometrial cancer. METHODS AND MATERIALS From October 1989 to August 1997, 36 patients presented with clinical stage I inoperable endometrial cancer. Surgery was precluded because of obesity and/or poor cardio-pulmonary reserve. Obesity was assessed using the body mass index (BMI) scale (kg/m2). Patients received 5 weekly HDR outpatient brachytherapy applications while under intravenous conscious sedation. Three-year clinical endpoints were calculated using the Kaplan and Meier method. Grade 3 and above complications were scored using the Radiation Therapy Oncology Group system. RESULTS The median age, Karnofsky performance status, BMI, and weight were 65 years old, 80%, 47 kg/m2, and 268 lbs, respectively. Nineteen patients were inoperable due to morbid obesity (median weight and BMI: 316 lbs and 56 kg/m2) while the remaining patients had other significant medical problems. Two patients died from acute cardiovascular events within 30 days of the last insertion. With a median follow-up of 32 months the 3-year uterine control, disease-free survival, survival, and complications were 88, 85, 65, and 21%, respectively. CONCLUSION Excellent uterine control rates (88%) were achieved using HDR brachytherapy for patients with medically inoperable endometrial cancer, but with significant acute and late morbidities. These toxicities were observed in a previous interim analysis that resulted in major modifications of the HDR program. No severe complications have developed since these changes were implemented. The current approach used for these challenging inoperable patients is a viable alternative to observation or hormonal therapy.
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Affiliation(s)
- T V Nguyen
- Department of Radiation Oncology, University of Wisconsin Medical School, Madison, WI 53792, USA
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Maingon P, Arnould L, Magnin V, Collin F, Belichard C, Fraisse J, Barillot I, d'Hombres A, Bône-Lepinoy MC, Padeano MM, Douvier S, Cuisenier J, Horiot JC. Preoperative radiotherapy and surgery for endometrial carcinoma: prognostic significance of the sterilization of the specimen. Int J Radiat Oncol Biol Phys 1998; 41:551-7. [PMID: 9635701 DOI: 10.1016/s0360-3016(98)00074-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We report a retrospective study on the analysis of the operative specimen after preoperative radiotherapy for FIGO (1971) stage I or II endometrial carcinoma. METHODS AND MATERIALS From 1976 to 1996, 221 patients were treated with external radiotherapy (XRT) and/or low-dose-rate brachytherapy (BT) followed by surgery (S). Patients with cervical involvement (89 patients) or with high-grade tumors (49 patients) received XRT and BT. Patients stage FIGO Ia (89 patients) or with low-grade tumors (57 patients) received BT alone. Surgery was performed 5 to 6 weeks after irradiation. RESULTS The mean follow-up is 78 months (12-216). The 5-year survival was 90% for FIGO Ia, 80% for FIGO Ib, and 84% for FIGO II (p = 0.51). According to the differentiation, 5-year survival was 87% for grade 1, 84% for grade 2, 84% for grade 3 (p = 0.10). Grade 3 complications were registered in 2% (no grade 4). The tumors were sterilized in 37 patients (17%), sterilized but with dystrophic glands in 34 patients (16%), only modified and altered in 21 patients (9.5%), with viable cells in 56 patients (26%). After preoperative radiotherapy, 37/148 specimens were sterilized (25%), 14/74 after brachytherapy and surgery (19%), 23/74 after external radiotherapy-brachytherapy and surgery (31%). According to the response of the specimen, 5-year survival was 87% when the tumor was sterilized, 96% when altered glands were present, 85% when modified, and 76% if residual tumor with viable cells was identified (p = 0.043). CONCLUSION Preoperative radiotherapy followed by surgery is a safe and effective treatment of FIGO stage I or II endometrial carcinomas. BT with two uterine tubes seems to be of interest in the contribution of the treatment of the uterus to sterilize the specimen. The analysis of this new prognostic factor remains important to select a population with worst prognosis.
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Affiliation(s)
- P Maingon
- Centre Georges-François Leclerc, Dijon, 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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Abstract
Carcinoma of the uterine corpus (endometrial cancer) remains the gynecologic malignant disease with the highest annual prevalence in the United States. The most common histologic type is adenocarcinoma, although more aggressive variants (e.g., papillary serous carcinoma and clear cell carcinoma) have been identified. Risk factors that are strongly associated with the development of endometrial cancer include tamoxifen therapy, obesity, and stimulation from unopposed estrogen (from exogenous sources or endogenously secreting ovarian tumors). The current staging system of the International Federation of Gynecology and Obstetrics is based on surgical-pathologic findings. Survival has been directly correlated with tumor stage in this staging system. The cornerstone of therapy is total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pelvic and para-aortic lymphadenectomy may provide additional prognostic information but probably does not confer a therapeutic advantage. Moreover, such nodal dissections predispose to the development of complications, especially in women who subsequently receive pelvic irradiation. Other than surgical treatment, irradiation is the single most active therapy for endometrial carcinoma. In fact, some women who are not candidates for hysterectomy because of medical contra-indications can be cured with radiation alone. Adjuvant therapy following hysterectomy is based on patient- and tumor-related features that provided prognostic information for incidence and pattern of recurrence. Adjuvant treatment usually includes pelvic irradiation for selected patients. Current investigational strategies are directed at the role of whole-abdomen irradiation, extended-field irradiation, and systemic chemotherapy. The most active systemic agents include cisplatin, doxorubicin, paclitaxel, and progestins.
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Affiliation(s)
- K M Greven
- Department of Radiation Oncology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
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Knocke TH, Kucera H, Weidinger B, Höller W, Pötter R. Primary treatment of endometrial carcinoma with high-dose-rate brachytherapy: results of 12 years of experience with 280 patients. Int J Radiat Oncol Biol Phys 1997; 37:359-65. [PMID: 9069308 DOI: 10.1016/s0360-3016(96)00486-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE This study aimed to evaluate the efficacy of high-dose-rate brachytherapy (HDRB) in the primary treatment of endometrial carcinoma. The results of 12 years of experience (1981-1992) covering 280 patients (mean age 72 years) and their follow-up over 10 years (mean 55 months) are reported. METHODS AND MATERIALS Staging was based on clinical examination and fractionated curettage. There were 116 patients in clinical Stage Ia, 119 in Stage Ib, 37 in Stage II, and 8 in Stage III. HDRB was performed four to five times (8.5 Gy) with a one-channel intracavitary applicator and one to two times (7 Gy) with an intravaginal cylinder applicator. Overall and disease-specific survival, local control according to stage and histology, and late side effects were analyzed retrospectively (actuarial method). RESULTS At 5 years, overall survival, disease-specific survival, and local control were 52.7%, 76.6%, and 75.4% (Stage Ia: 63.9%, 84.9%, and 86.0%; Stage Ib: 47.3%, 73.3%, and 68.8%; and Stage II: 40.2%, 68.6%, and 60.5%) according to histopathologic Grade 1: 65.1%, 83.5%, and 77.7%; for Grade 2: 44.7 %, 75.4%, and 75.8%; and for Grade 3: 37.7%, 63.9%, and 74.1%. Eight patients showed progressive disease, 64 developed recurrence after a median of 13 months (45 of whom had a local recurrence only, and 6 of whom had a local recurrence with distant metastases), 6 developed a lymph node recurrence only, and 7 developed distant metastases only. The calculated probability for developing a Grade III late side effect was 5.2% at 5 years. CONCLUSION At Stages Ia, Ib, and II in endometrial carcinoma, HDRB is a very effective treatment modality with acceptable local control rates and disease-specific survival for patients who are not fit for surgery. During the time frame of 12 years and in 280 patients the method has proven to have a low risk of acute complications and an acceptable risk of long-term side effects.
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Affiliation(s)
- T H Knocke
- Department of Radiotherapy and Radiobiology, University of Vienna, Austria
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Affiliation(s)
- P G Rose
- Department of Reproductive Biology, University Hospitals of Cleveland, OH 44107, USA
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Maingon P, Horiot JC, Fraisse J, Salas S, Collin F, Bône-Lepinoy MC, Barillot I, Douvier S, Padéano MM, Cuisenier J. Preoperative radiotherapy in stage I/II endometrial adenocarcinoma. Radiother Oncol 1996; 39:201-8. [PMID: 8783396 DOI: 10.1016/0167-8140(96)01743-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
From 1972 to 1993, 170 patients received preoperative radiotherapy followed, 5-6 weeks later, by total extrafascial hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy. Eighty-three patients with good prognostic factors (low grade tumour and no cervical involvement) received low dose rate utero vaginal brachytherapy alone before surgery (Group 1). Eighty-seven patients with poor prognostic factors (high grade tumors and/or cervical involvement) received external radiotherapy to 40 Gy and low dose rate brachytherapy before surgery (Group 2). A single vaginal failure was observed (0.6%). The overall pelvic failure rate was 2.3% (four patients) including two cases with pelvic recurrence and metastases. Three of the four pelvic failures occurred in Group 1. Using the 1971 FIGO clinical staging, 5-year disease-free survival was 82% in Stage Ia, 79% in Stage Ib, and 81% in Stage II (P = 0.36). Five-year disease-free survival was 86% in Grade 1, 76% in Grade 2, and 83% in Grade 3 (P = 0.20). Five-year overall survival was 83% in Stage Ia, 79% in Stage Ib, and 83% in Stage II (P = 0.78). Five-year overall survival was 88% in Grade 1, 77% in Grade 2,83% in Grade 3 (P = 0.27). Complications were recorded with the French-Italian syllabus. Grade 2 complications occurred in 12 cases (7%), Grade 3 in five cases (3%). The lack of correlation between classical risk factors (stage, grade) and disease outcome suggests that preoperative radiotherapy strategies should be preferred when such factors can be identified before surgery.
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Affiliation(s)
- P Maingon
- Centre Georges-François-Leclerc, Dijon, France
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Abstract
This synthesis of the literature on radiotherapy for cancer originating in the endometrium of the uterus (corpus uteri) is based on 55 scientific articles, including 2 randomized studies, 1 prospective study, and 48 retrospective studies. These studies involve 13597 patients. Endometrial cancer is a radiosensitive cancer. Research findings compiled for the period 1948 to 1954 showed that 69% of the patients could be cured by radiotherapy alone. During the 1970s it was shown that combined radiotherapy and surgery yielded better results. There is agreement that patients at stage I should receive primary surgery. According to the literature, there is controversy about whether patients with poorly differentiated tumors should be given preoperative radiotherapy. Radiotherapy alone can be used successfully in patients who are inoperable because of age, general condition, or advanced spread of cancer. Vaginal postoperative radiotherapy is used in most patients and reduces the percentage of patients who develop vaginal metastases from 7%-20% to less than 1%. Patients with good prognostic factors have such a low risk for metastasis that withholding radiotherapy may be considered in this group. Postoperative external radiotherapy improves survival in patients with unfavorable prognostic factors, such as deep myometrium invasion or signs of node metastasis. Radiotherapy is delivered, in principle, to all patients with poorly differentiated disease. It can be expected that most cases of endometrial cancer will continue to be referred for some form of radiotherapy.
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