Twice-per-day fractionated high versus continuous low dose rate intracavitary therapy in the radical treatment of cervical cancer: a nonrandomized comparison of treatment results

Low-Dose-Rate versus High-Dose-Rate intracavitary brachytherapy in cervical cancer - Final Results of a Phase III randomized trial

PURPOSE

Intracavitary brachytherapy using High-Dose-Rate (HDR) and Low-dose-rate (LDR) in cervical cancer has been utilized. We report the long-term final results of a large randomized trial in terms of toxicities and efficacy.

METHODS AND MATERIALS

Between 1996 to 2005, 816 patients were randomized to LDR (n = 441 patients) or HDR brachytherapy (n = 369 patients) stratified by FIGO Stage grouping. Patients with Stage I-II received external irradiation of 40 Gy in 20 fractions (with midline block (MLB)) followed by either 2 LDR Intracavitary applications of 30 Gy to point A (2-3 weeks apart) or 5 HDR Intracavitary applications of 7 Gy to point A once weekly. Patients with Stage III received 50 Gy in 25 fractions (with MLB after 40 Gy) followed by either one application of LDR 30 Gy to point A or three applications of HDR 7 Gy to point A once weekly.

RESULTS

With a median follow-up was 64 months (interquartile range [IQR]: 21 - 111), moderate to severe rectal and bladder complications were higher in LDR arm as compared to HDR arm (9.7% vs. 3.6%; p = 0.02) and (10.5% vs. 5.5%; p = 0.06) for Stage I-II. No difference in rectal or bladder complications for Stage III patients. Disease free and overall survivals were similar in both the arms for all stages.

CONCLUSIONS

HDR intracavitary brachytherapy with 7 Gy per fraction weekly is superior to LDR in terms of late rectal and bladder complications. Local control rates and survivals are similar irrespective of stages.

Toxicities and Recurrences after Co-60 High-Dose-Rate Brachytherapy for Cervical Cancer in a Tertiary Government Hospital in the Philippines

Introduction Despite the rising popularity of high-dose-rate (HDR) brachytherapy and use of Co-60 in the country, local data on brachytherapy outcomes are lacking. The study reviewed the incidence of toxicities and recurrences in patients with cervical cancer treated with Co-60 intracavitary HDR brachytherapy in a tertiary government hospital in the Philippines.

Methods Records of patients with cervical cancer who completed external beam radiotherapy (EBRT) and brachytherapy from 2016 to 2018 were reviewed. Patient-related (age, smoking history, body mass index, histology, stage, mass size) and treatment-related (overall treatment time [OTT], EBRT machine used, brachytherapy fractionation, dose prior to midline shielding/central tumor dose [CTD]) parameters were analyzed for possible associations with the incidence of toxicities and recurrences.

Results One hundred and sixty-three patients were identified and reviewed for baseline characteristics. Patients who had inadequate follow-up (<90 days) were excluded in the analysis of outcomes. Among the remaining 132 patients, median follow-up duration was 389 days. Gastrointestinal (GI) and genitourinary (GU) toxicities were present in 19.7% (n = 26) and 1.5% (n = 2), respectively. Recurrence was noted in 31.8% (n = 42). The most commonly involved sites of locoregional and distant recurrence was the uterocervix (n = 16, 59.3%) and para-aortics (n = 42, 31.8%), respectively. CTD was significantly associated with toxicities (p = 0.03), while OTT was borderline significantly associated with recurrence (p = 0.06).

Conclusion We present outcomes of GI and GU toxicities, and locoregional and distant recurrences after chemoradiation and Co-60 HDR brachytherapy in a tertiary government hospital in the Philippines. Our study suggests that CTD was significantly associated with incidence of toxicities, while OTT was weakly associated with recurrence. Interventions should be made to control these factors, especially in high-volume, low-resource cancer centers.

High-dose-rate vs. low-dose-rate intracavitary brachytherapy for carcinoma of the uterine cervix: Systematic review and meta-analysis

PURPOSE

We performed a meta-analysis to compare the treatment outcomes between high-dose-rate (HDR) and low-dose-rate (LDR) intracavitary brachytherapy (ICBT) for the treatment of cervical cancer.

METHODS AND MATERIALS

We searched the PubMed database for articles and the related referenced articles that compared HDR-ICBT and LDR-ICBT. A total of 15 published articles, 3 prospective randomized trials, and 12 retrospective studies performed between 1966 and December 2013 were selected using predefined inclusion and exclusion criteria for each study. The effect sizes were obtained from the odds ratios of the 5-year overall survival, 5-year disease-free survival (DFS), pelvic (locoregional) recurrence, and rectal and bladder complication rates in each study. The common effect sizes and 95% confidence intervals (CIs) were calculated using either the fixed or the random-effect model, according to the results of the homogeneity tests.

RESULTS

We analyzed the outcome data for 18,937 patients, including 10,807 patients in the HDR-ICBT treatment group and 8,130 patients in the LDR-ICBT group. The common effect sizes (95% CI) for the 5-year survival rate, 5-year DFS rate, and pelvic recurrence rate were 1.1350 (0.9231-1.3955), 1.0777 (0.4896-2.3720), and 0.9521 (0.7624-1.1890), respectively. The common effect sizes (95% CI) for moderate-to-severe complication rates of the rectum and the bladder were 0.7645 (0.5099-1.1463) and 0.9051 (0.6140-1.3342), respectively. There were no significant differences between HDR- and LDR-ICBT considering the 5-year survival, 5-year DFS, pelvic recurrence, and the rectal and bladder complication rates.

CONCLUSION

The treatment outcome after HDR-ICBT seems to be equivalent to that following LDR-ICBT in terms of survival, pelvic recurrence, and major complications.

High versus low-dose rate brachytherapy for cervical cancer

OBJECTIVES

Brachytherapy plays an important role in the treatment of cervical cancer. While small trials have shown comparable survival outcomes between high (HDR) and low-dose rate (LDR) brachytherapy, little data is available in the US. We examined the utilization of HDR brachytherapy and analyzed the impact of type of brachytherapy on survival for cervical cancer.

METHODS

Women with stages IB2-IVA cervical cancer treated with primary (external beam and brachytherapy) radiotherapy between 2003-2011 and recorded in the National Cancer Database (NCDB) were analyzed. Generalized linear mixed models and Cox proportional hazards regression were used to examine predictors of HDR brachytherapy use and the association between HDR use and survival.

RESULTS

A total of 10,564 women including 2681 (25.4%) who received LDR and 7883 (74.6%) that received HDR were identified. Use of HDR increased from 50.2% in 2003 to 83.9% in 2011 (P<0.0001). In a multivariable model, year of diagnosis was the strongest predictor of use of HDR. While patients in the Northeast were more likely to receive HDR therapy, there were no other clinical or socioeconomic characteristics associated with receipt of HDR. In a multivariable Cox model, survival was similar between the HDR and LDR groups (HR=0.93; 95% CI 0.83-1.03). Similar findings were noted in analyses stratified by stage and histology. Kaplan-Meier analyses demonstrated no difference in survival based on type of brachytherapy for stage IIB (P=0.68), IIIB (P=0.17), or IVA (P=0.16) tumors.

CONCLUSIONS

The use of HDR therapy has increased rapidly. Overall survival is similar for LDR and HDR brachytherapy.

Study of positional dependence of dose to bladder, pelvic wall and rectal points in High-Dose-Rate Brachytherapy in cervical cancer patients

The objective of the study is to examine the variation in doses to, Bladder, pelvic wall and Rectal Points when a patient is simulated in Supine (S Position) and Lithotomy M shaped positions (LM Position), respectively as part of Intracavitary Brachytherapy in Cervical Cancer patients. Patients (n = 19) were simulated and orthogonal images were taken in S Position and LM Positions on a physical simulator. Digital orthogonal X-ray images were transferred to Brachyvision Treatment Planning System via Dicom to generate treatment plans. Radio opaque dye of 7 ml was injected into the Foley bulb for identification and digitization of International Commission on Radiological Units and Measurements (ICRU) Bladder point. Pelvic side wall points were marked in accordance with ICRU 38 recommendations. A Rectal tube containing dummy source marker wire was used to identify Rectal Point. Students't-test was used to analyze the results. Doses in LM Position were lower and statistically significant when compared to S Position for ICRU Bladder Point, pelvic walls and Rectal Point. It was observed that movement of applicator could be the reason for the variations in doses between the two positions. Bladder, pelvic wall and rectal points systematically registered lower doses in LM Position as compared to S Position.

Changes in applicator positions and dose distribution between high dose rate brachytherapy fractions in cervix carcinoma patients receiving definitive radiotherapy

This study examines the change of applicator geometry and its effect on rectal/rectum (R) and bladder (B) doses, and obtained radiobiological equivalent doses (RED), between each high dose rate (HDR) brachytherapy (BT) fraction in cervical carcinoma patients. BT using a tandem (T) and two ovoids (O) is included, and any discrepancies in applicator positions among the fractions were calculated. Whether the change of applicator position had an effect on the calculated R and B doses was analysed. Furthermore, the relationship between the size of tumour, the magnitude of displacement and the change in R and B doses was also investigated. Lastly, the changes in R and B RED were noted. The average magnitude of displacement was between 2.0 mm and 16.9 mm, showing time trend. There was no relationship between tumour size and the magnitude of discrepancy of Left O, Right O, T, R, B, and neither change in R and B doses (p>0.05). The mean differences of R and B doses were between 49-78 cGy, and 70-84 cGy, respectively. The magnitude of discrepancy and changes in doses showed no correlation (p>0.05). There were no significant differences in REDs for bladder (p = 0.8) and rectum (p = 0.2). In conclusion, there were significant differences in the applicator positions R and B and R and B doses among the fractions, which confirm the necessity of treatment planning in each HDR BT fraction. However, the total calculated R and B REDs did not show a remarkable difference.

Current controversies in high-dose-rate versus low-dose-rate brachytherapy for cervical cancer

The use of brachytherapy in the treatment of cervical cancer has increased worldwide since its initial introduction over 100 years ago. However, certain aspects of the use of high-dose-rate (HDR) versus low-dose-rate (LDR) brachytherapy continue to be controversial, particularly the role of HDR in FIGO Stage III cervical cancer and the use of HDR with concurrent chemotherapy. This study represents a systematic literature review of prospective and retrospective series of patients with cervical carcinoma treated with external-beam radiation (EBRT) followed by either HDR or LDR radiation. The local control rates, survival rates, and treatment-related complications in patients with Stage III cervical cancer treated with HDR or LDR and those treated with concomitant chemotherapy are examined. Patients with Stage III cervical cancer treated with EBRT and brachytherapy have a local control rate of >50% in most series. Randomized prospective and retrospective studies show overall statistically equivalent local control, overall survival, and complication rates between HDR and LDR. However, LDR may be preferable for large, bulky tumors at the time of brachytherapy. Retrospective studies of HDR and concurrent chemotherapy are limited but have demonstrated toxicity rates similar to those with LDR. Selected patients with Stage III cervical carcinoma who have an adequate response to EBRT and concomitant chemotherapy may be treated with HDR brachytherapy. The existing literature shows no significant increase in complications in patients treated with HDR and concurrent chemotherapy; however, sufficient tumor shrinkage prior to HDR and careful monitoring of the dose to the normal tissues are imperative.

Risk stratification of patients with advanced squamous cell carcinoma of cervix treated by radiotherapy alone

PURPOSE

To identify prognostic factors for local and distant relapse and perform risk stratification for patients with advanced cervical cancer treated with radiotherapy (RT) alone.

METHODS AND MATERIALS

A total of 1031 patients with Stage IB-IVA squamous cell carcinoma of the cervix treated with full-course RT but without any chemotherapy were included for analysis. Of these, 311 patients with nonbulky Stage IB-IIA disease were designated the reference group and the other 720 patients were the study group. The associations of stage, squamous cell carcinoma antigen (SCC-ag) level, hemoglobin level, age, cell differentiation, and pelvic lymph node status with treatment failure were evaluated. The independent prognostic factors were identified by multivariate analysis. The study group was further stratified into subgroups using combinations of these risk factors.

RESULTS

In the study group, independent risk factors for local relapse were advanced stage and age <45 years. The 5-year local relapse-free survival rate was 86% for patients > or =45 years with bulky Stage IB-IIA or IIB disease, and was even greater, up to 90% if the SCC-ag level was <2. In contrast, it was 65% for patients with Stage IIIB who were <45 years old. The independent risk factors for distant failure were advanced stage, SCC-ag level >2, and positive pelvic lymph nodes. The 5-year distant relapse-free survival rate was 83% for patients with bulky Stage IB-IIA and IIB disease, SCC-ag level <2, and negative lymph nodes and 43% for patients with Stage III, SCC-ag level >2, and positive lymph nodes.

CONCLUSION

The risk of treatment failure in advanced-stage cervical cancer patients treated by RT alone can be more precisely predicted by risk stratification. A certain subgroup of patients had better control than the others. The benefit of treating these relatively low-risk patients with additional treatment such as concurrent chemotherapy should be further evaluated in prospective studies or meta-analyses.

Long-term follow-up of RTOG 88-05: twice-daily external irradiation with brachytherapy for carcinoma of the cervix

PURPOSE

To evaluate the efficacy and toxicity of twice-daily external irradiation to the pelvis with brachytherapy for carcinoma of the cervix in a long-term follow-up study.

METHODS AND MATERIALS

This study was designed to administer twice-daily irradiation doses of 1.2 Gy to the pelvis, 5 d/wk. Radiotherapy also included one or two low-dose-rate intracavitary implants, to deliver a total minimal dose of 85 Gy to point A and 65 Gy to the lateral pelvic lymph nodes.

RESULTS

Eighty-one patients with clinical Stage IB-IVA carcinoma of the cervix were enrolled in this prospective, single arm, Phase I/II study. Hyperfractionated irradiation was completed in 88%. Brachytherapy was given in two implants in 46% and in one implant in 54%. Six patients had acute Grade 3 toxicities. The cumulative rate of Grade 3 and 4 late effects for patients with Stage IB2, IIA, and IIB disease was 7% at 3 years, 7% at 5 years, and 10% at 8 years. For patients with Stage III and IVA disease, the rate of late toxicities (Grades 3 and 4) was 7% at 3 years and 12% at 5 years. The site of first failure was in the pelvis in 41%, para-aortic or supraclavicular lymph nodes in 6%, and other distant metastatic sites in 14%. The absolute survival rate was 61% at 3 years, 48% at 5 years, and 45% at 8 years. The disease-free survival rate was 43% at 3 years, 38% at 5 years, and 33% at 8 years.

CONCLUSION

The results suggest that, combined with brachytherapy, hyperfractionated irradiation to total parametrial doses about 10% greater than doses administered with standard fractionation pelvic irradiation was tolerated and at least appears to be as effective as standard fractionation pelvic irradiation.

High-dose-rate brachytherapy may be radiobiologically superior to low-dose rate due to slow repair of late-responding normal tissue cells

BACKGROUND AND PURPOSE

Recent analysis of morbidity for patients treated with the continuous hyperfractionated accelerated radiotherapy (CHART) regimen demonstrates that repair half-times for late-reacting normal tissue cells are of the order of 4-5 h, which is considerably longer than previously believed. This would reduce repair of these tissue cells during a course of low-dose rate (LDR) brachytherapy, but have no effect at high-dose-rate (HDR), where there is no repair during, and full repair between fractions, regardless of repair half-time. The effect this has upon radiobiologic comparison of LDR and HDR is the topic of this paper.

METHODS AND MATERIALS

The linear-quadratic (L-Q) model is used to compare late-effect biologically effective doses (BEDs) of LDR and HDR, for constant BED (tumor). The effects of dose rate (for LDR), fractionation (for HDR), and geometrical sparing of normal tissues are all considered. Repair half-times observed in the CHART study are used to investigate the potential impact of long repair times on the comparison of LDR and HDR.

RESULTS

It is demonstrated that, for a repair half-time of 1.5 h for tumor cells, if the half-time for repair of late-reacting normal tissue cells exceeds about 2.5 h, LDR becomes radiobiologically inferior to HDR. Even with the least HDR-favorable combinations of parameters, HDR at over about 5 Gy/fraction ought to be radiobiologically superior to LDR at 0.5 Gy/h, so long as the time between HDR fractions is long compared to the repair half time. It is also shown that any geometrical sparing of normal tissues will benefit HDR more than LDR.

CONCLUSION

The previously held belief that LDR must be inherently superior radiobiologically to HDR is wrong if the long repair times demonstrated in the recent CHART study are applicable to other late-reacting normal tissues. This could explain why HDR has been so successful in clinical practice, especially for the treatment of cervical cancer, despite previous convictions of radiobiologic inferiority of this modality.

Randomized trial of neoadjuvant cisplatin, vincristine, bleomycin, and radical hysterectomy versus radiation therapy for bulky stage IB and IIA cervical cancer

PURPOSE

To compare the efficacy of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy with that of radiotherapy (R/T) for bulky early-stage cervical cancer.

PATIENTS AND METHODS

Women with previously untreated bulky (primary tumor >/= 4 cm) stage IB or IIA non-small-cell carcinoma of the uterine cervix were randomly assigned to receive either cisplatin 50 mg/m(2) and vincristine 1 mg/m(2) for 1 day and bleomycin 25 mg/m(2) for 3 days for three cycles followed by radical hysterectomy (NAC arm) or receive primary pelvic radiotherapy only (R/T arm). The ratio of patient allocation was 6:4 for the NAC and R/T arms. Women with enlarged para-aortic lymph nodes on image study were ineligible unless results of cytologic or histologic studies were negative.

RESULTS

Of the 124 eligible patients, 68 in the NAC arm and 52 in the R/T arm could be evaluated. The median duration of follow-up was 39 months. Thirty-one percent of patients in the NAC arm and 27% in the R/T arm had relapse or persistent diseases after treatment, and 21% in each group died of disease. Estimated cumulative survival rates at 2 years were 81% for the NAC arm and 84% for the R/T arm; the 5-year rates were 70% and 61%, respectively. There were no significant differences in disease-free survival and overall survival.

CONCLUSION

NAC followed by radical hysterectomy and primary R/T showed similar efficacy for bulky stage IB or IIA cervical cancer. Further study to identify patient subgroups better suited for either treatment modality and to evaluate the concurrent use of cisplatin and radiation without routine hysterectomy is necessary.

Treatment results and prognostic factors in inoperable carcinoma of the cervix treated with external plus high dose brachytherapy

Patients with inoperable carcinoma of the cervix treated with external plus high dose rate brachytherapy (HDRB), between 1988 and 1995 were evaluated retrospectively. According to stage, 5 year survival rates were 67.3% in stage IIb and 52.6% in stage III (P = 0001) and disease free survival (DFS) rates were 54.0% in stage IIb and 43.9% in stage III (P = 0.01). The following parameters were studied: age; stage; external beam dose; brachytherapy dose; total dose to point A; tumor mass; tumor response rate; bilateral or unilateral invasion of parametria in stage IIb; and bilateral or unilateral invasion of pelvic wall in stage IIIb; and the existence of hydronephrosis. The only significant parameter of 5 year survival and local control was tumor mass (P = 0.003).

The prognostic significance of pre- and posttreatment SCC levels in patients with squamous cell carcinoma of the cervix treated by radiotherapy

PURPOSE

To investigate the prognostic significance of the pre- and posttreatment serum squamous cell carcinoma antigen (SCC) levels in patients with Stage I-IVA squamous cell carcinoma of the cervix primarily treated by radiotherapy.

MATERIALS AND METHODS

401 patients with squamous cell carcinoma of cervix primarily treated with radiotherapy (RT) were included in this study. All had preRT, and 249 patients had postRT serum SCC values. The association of pretreatment SCC level with the clinical parameters, including stage, hemoglobin (Hb) level, age, cell differentiation, and lymph node status, was assessed by univariate and multivariate analysis. The prognostic significance of pretreatment SCC level and these clinical parameters were evaluated. The impact of postRT residual induration and SCC levels on survival was analyzed.

RESULTS

1. PreRT SCC level strongly correlated with stage. After controlling for stage, only SCC levels higher than 10 ng/ml were associated with enlarged lymph nodes shown in CT scan. No association of preRT SCC level with other clinical parameters was found. 2. SCC level higher than 10 ng/ml, but not between 2-10 ng/ml, had significant impact on survival in a multivariate analysis. Stage, Hb levels (<10 g/dl) and positive lymph node shown by CT scan were also independent prognostic factors for survival. No significant difference in failure pattern in terms of local and/or distant sites was found in patients with different SCC levels. 3. Patients with residual induration and/or persistently elevated SCC level at 2-3 months after RT had a significantly higher incidence of treatment failure. Persistently elevated SCC level is a stronger predictor for treatment failure than residual induration by pelvic examination, and is associated with a higher incidence of distant metastasis. One third of patients with initial SCC level higher than 10 ng/ml had persistently elevated SCC.

CONCLUSION

Pretreatment SCC levels higher than 10 ng/ml are an independent predictor for poor prognosis in patients included in this study, and can be used as one of the prognostic factors for selection of patients for intensive treatment. Persistently elevated SCC levels after RT is a strong predictor for treatment failure. A combination of clinical pelvic examination and SCC levels provides useful information for the need of further work-up and management.

High-dose-rate intracavitary brachytherapy (HDR-IC) in treatment of cervical carcinoma: 5-year results and implication of increased low-grade rectal complication on initiation of an HDR-IC fractionation scheme

PURPOSE

To report the treatment results and rectal/bladder complications of cervical carcinoma radically treated with high-dose-rate intracavitary brachytherapy (HDR-IC). The current policy of using three-fraction scheme was examined.

METHODS AND MATERIALS

Between November 1987 and August 1990, 173 patients with cervical carcinoma were treated with curative-intent radiation therapy. Whole pelvic irradiation was administered with 10-MV X ray. Dose to the central cervix was 40-44 Gy in 20-22 fractions, following by pelvic wall boost 6-14 Gy in three to seven fractions with central shielding. 60Co sources were used for HDR-IC, and 7.2 Gy was given to Point A for three applications, 1-2 weeks apart. Duration of follow-up was 5-7.8 years.

RESULTS

Twenty-eight patients (16%) developed central-regional recurrences. Overall 5-year actuarial pelvic control rate was 83%. By stage, 5-year actuarial pelvic control rates were 94%, 87%, and 72% for Stages IB + IIA, IIB + IIIA, and IIIB + IVA, respectively. Thirty-one patients (18%) developed distant metastasis. Overall 5-year actuarial survival rate was 58%. By stage, 5-year actuarial survival rates were 79%, 59%, and 41% for Stages IB + IIA, IIB + IIIA, and IIIB + IVA, respectively. Sixty-six (38%) and 19 patients (11%) developed rectal and bladder complications, respectively. For rectal complication, the overall actuarial rate was 38% at 5 years. By grade, 5-year actuarial rectal complication rates were 24%, 15%, 4%, and 3% for Grades 1-4, respectively. Overall prevalence of rectal complications was 37% and 14% at 2 and 5 years, respectively. Prevalence of low-grade rectal complication (Grades 1 and 2) was dominant at 2 years (30%), but declined to 8% at 5 years. Prevalence of high-grade, severe rectal complication (Grades 3 and 4) remained steady at 2 and 5 years (7% and 6%, respectively). Five-year actuarial bladder complication was 9%. Five-year prevalence of bladder complication was 2%.

CONCLUSION

Using a three-fraction scheme, survival rate appeared comparable with the existing results of the low-dose-rate technique. The incidence of rectal complication with this scheme remained relatively high. The increased part of rectal complication was predominantly low grade. This result suggested that therapeutic gain with this scheme may not be good enough to circumvent its biologic disadvantage. Numbers of fractions >3 must be considered in future trials.