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Baral SK, Biswas P, Kaium MA, Islam MA, Dey D, Saber MA, Rahaman TI, M A, Emran TB, Hasan MN, Jeong MK, Han I, Rahman MA, Kim B. A Comprehensive Discussion in Vaginal Cancer Based on Mechanisms, Treatments, Risk Factors and Prevention. Front Oncol 2022; 12:883805. [PMID: 35924174 PMCID: PMC9341270 DOI: 10.3389/fonc.2022.883805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/23/2022] [Indexed: 12/27/2022] Open
Abstract
Vaginal cancer is a rare and uncommon disease that is rarely discussed. Although vaginal cancer traditionally occurs in older postmenopausal women, the incidence of high-risk human papillomavirus (HPV)-induced cancers is increasing in younger women. Cervical cancer cells contain high-risk human papillomavirus (HPV) E6 and E7 proteins and inhibiting HPV gene expression leads the cells to stop proliferating and enter senescence. As E6, and E7 protein promoted the carcinogenesis mechanism, and here not only regulate the cellular degradation of P53, and pRb but also enhances the cell proliferation along with E6 protein targets the p53 for breakdown and subsequently promote the apoptotic cell death, and DNA repair inhibition, that is indispensable to the continue the lifecycle of the HPV. As a synchronous or metachronous tumor, vaginal cancer is frequently found in combination with cervical cancer. It is uncertain what causes invasive female vaginal organ cancer. HPV type 16 is the most often isolated HPV type in female vaginal organ cancers. Due to cancer’s rarity, case studies have provided the majority of etiologic findings. Many findings demonstrate that ring pessaries, chronic vaginitis, sexual behavior, birth trauma, obesity, vaginal chemical exposure, and viruses are all risk factors. Because of insufficient understanding and disease findings, we are trying to find the disease’s mechanism with the available data. We also address different risk factors, therapy at various stages, diagnosis, and management of vaginal cancer in this review.
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Affiliation(s)
| | - Partha Biswas
- Department of Genetic Engineering and Biotechnology, Faculty of Biological Science and Technology, Jashore University of Science and Technology (JUST), Jashore, Bangladesh
- ABEx Bio-Research Center, Dhaka, Bangladesh
| | - Md. Abu Kaium
- Department of Genetic Engineering and Biotechnology, Faculty of Biological Science and Technology, Jashore University of Science and Technology (JUST), Jashore, Bangladesh
| | - Md. Aminul Islam
- Department of Genetic Engineering and Biotechnology, Faculty of Biological Science and Technology, Jashore University of Science and Technology (JUST), Jashore, Bangladesh
| | - Dipta Dey
- Biochemistry and Molecular Biology department, Life Science faculty, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalgonj, Bangladesh
| | - Md Al Saber
- Biotechnology, University of Pécs, Medical School, Pécs, Hungary
| | - Tanjim Ishraq Rahaman
- Department of Biotechnology and Genetic Engineering, Faculty of Life Science, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
| | - A. M
- Department of Microbiology, Chittagong University, Chittagong, Bangladesh
| | - Talha Bin Emran
- Department of Pharmacy, Begum Gulchemonara (BGC) Trust University Bangladesh, Chittagong, Bangladesh
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, Bangladesh
| | - Md. Nazmul Hasan
- Laboratory of Pharmaceutical Biotechnology and Bioinformatics, Department of Genetic Engineering and Biotechnology, Jashore University of Science and Technology, Jashore, Bangladesh
| | - Mi-Kyung Jeong
- Korean Medicine (KM) Convergence Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Ihn Han
- Plasma Bioscience Research Center, Kwangwoon University, Seoul, South Korea
| | - Md. Ataur Rahman
- Global Biotechnology & Biomedical Research Network (GBBRN), Department of Biotechnology and Genetic Engineering, Faculty of Biological Sciences, Islamic University, Kushtia, Bangladesh
- Department of Pathology, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
- Korean Medicine-Based Drug Repositioning Cancer Research Center, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
- *Correspondence: Md. Ataur Rahman, ; Bonglee Kim,
| | - Bonglee Kim
- Department of Pathology, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
- Korean Medicine-Based Drug Repositioning Cancer Research Center, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
- *Correspondence: Md. Ataur Rahman, ; Bonglee Kim,
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Westerveld H, Schmid MP, Nout RA, Chargari C, Pieters BR, Creutzberg CL, Sturdza A, Lindegaard JC, van Kesteren Z, Mazeron R, Nesvacil N, Fokdal LU. Image-Guided Adaptive Brachytherapy (IGABT) for Primary Vaginal Cancer: Results of the International Multicenter RetroEMBRAVE Cohort Study. Cancers (Basel) 2021; 13:1459. [PMID: 33806733 PMCID: PMC8004779 DOI: 10.3390/cancers13061459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE This study assessed outcomes following the nowadays standing treatment for primary vaginal cancer with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT) in a multicenter patient cohort. METHODS Patients treated with computer tomography (CT)-MRI-assisted-based IGABT were included. Retrospective data collection included patient, tumor and treatment characteristics. Late morbidity was assessed by using the CTCAE 3.0 scale. RESULTS Five European centers included 148 consecutive patients, with a median age of 63 years. At a median follow-up of 29 months (IQR 25-57), two- and five-year local control were 86% and 83%; disease-free survival (DFS) was 73% and 66%, and overall survival (OS) was 79% and 68%, respectively. Crude incidences of ≥ grade-three urogenital, gastro-intestinal and vaginal morbidity was 8%, 3% and 8%, respectively. Lymph node metastasis was an independent prognostic factor for disease-free survival (DFS). Univariate analysis showed improved local control in patients with T2-T4 tumors if >80 Gy EQD2α/β10 was delivered to the clinical target volume (CTV) at the time of brachytherapy. CONCLUSIONS In this large retrospective multicenter study, IGABT for primary vaginal cancer resulted in a high local control with acceptable morbidity. These results compared favorably with two-dimensional (2D) radiograph-based brachytherapy and illustrate that IGABT plays an important role in the treatment of vaginal cancer.
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Affiliation(s)
- Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Maximilian P. Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Remi A. Nout
- Department of Radiation Oncology, Leiden University Medical Center, 2333 Leiden, The Netherlands; (R.A.N.); (C.L.C.)
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 Rotterdam, The Netherlands
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Université Paris Saclay, 94805 Villesuif, France;
| | - Bradley R. Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Carien L. Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, 2333 Leiden, The Netherlands; (R.A.N.); (C.L.C.)
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Jacob C. Lindegaard
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (J.C.L.); (L.U.F.)
| | - Zdenko van Kesteren
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Université Paris Saclay, 94805 Villesuif, France;
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Lars U. Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (J.C.L.); (L.U.F.)
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Westerveld H, Nesvacil N, Fokdal L, Chargari C, Schmid MP, Milosevic M, Mahantshetty UM, Nout RA. Definitive radiotherapy with image-guided adaptive brachytherapy for primary vaginal cancer. Lancet Oncol 2020; 21:e157-e167. [PMID: 32135119 DOI: 10.1016/s1470-2045(19)30855-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/27/2022]
Abstract
Primary vaginal cancer is a rare cancer and clinical evidence to support recommendations on its optimal management is insufficient. Because primary vaginal cancer resembles cervical cancer in many aspects, treatment strategies are mainly adopted from evidence in locally advanced cervical cancer. To date, the organ-sparing treatment of choice is definitive radiotherapy, consisting of external beam radiotherapy and brachytherapy, combined with concurrent chemotherapy. Brachytherapy is an important component of the treatment and its steep dose gradient enables the delivery of high doses of radiation to the primary tumour, while simultaneously sparing the surrounding organs at risk. The introduction of volumetric CT or MRI image-guided adaptive brachytherapy in cervical cancer has led to better pelvic control and survival, with decreased morbidity, than brachytherapy based on x-ray radiographs. MRI-based image-guided adaptive brachytherapy with superior soft-tissue contrast has also been adopted sporadically for primary vaginal cancer. This therapy has had promising results and is considered to be the state-of-the-art treatment for primary vaginal cancer in standard practice.
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Affiliation(s)
- Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, AMC, Amsterdam, Netherlands.
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Université Paris Saclay, France; Institut de Recherche Biomédicale des Armées, Brétigny-sur-Orge, France
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Michael Milosevic
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre and Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Umesh M Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Remi A Nout
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
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Schmid MP, Fokdal L, Westerveld H, Chargari C, Rohl L, Morice P, Nesvacil N, Mazeron R, Haie-Meder C, Pötter R, Nout RA. Recommendations from gynaecological (GYN) GEC-ESTRO working group - ACROP: Target concept for image guided adaptive brachytherapy in primary vaginal cancer. Radiother Oncol 2019; 145:36-44. [PMID: 31874348 DOI: 10.1016/j.radonc.2019.11.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM External beam radiotherapy (EBRT) combined with brachytherapy has an essential role in the curative treatment of primary vaginal cancer. EBRT is associated with significant tumour shrinkage, making primary vaginal cancer suitable for image guided adaptive brachytherapy (IGABT). The aim of these recommendations is to introduce an adaptive target volume concept for IGABT of primary vaginal cancer. METHODS In December 2013, a task group was initiated within GYN GEC-ESTRO with the purpose to introduce an IGABT target concept for primary vaginal cancer. All participants have broad experience in IGABT and vaginal cancer brachytherapy. The target concept was elaborated as consensus agreement based on an iterative process including target delineation and dose planning comparison, retrospective analysis of clinical data and expert opinions. RESULTS Gynaecological examination and MR imaging are the modalities of choice for local tumour assessment. A specific template for standardised documentation with clinical drawings for vaginal cancer was developed. The adaptive target volume concept comprises different response-related target volumes. For EBRT these are related to the primary tumour and the lymph nodes, while for IGABT these are related to the primary tumour and are consisting of the residual gross tumour volume (GTV-Tres) and the high-, and intermediate risk clinical target volumes (CTV-THR, CTV-TIR). CONCLUSION This target concept for IGABT of primary vaginal cancer defines adaptive target volumes for volumetric dose prescription and should improve comparability of different radiotherapy schedules of this rare disease. A prospective evaluation of the target volume concept within a multicentre study is planned.
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Affiliation(s)
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Henrike Westerveld
- Department of Radiotherapy, Amsterdam University Medical Centers, AMC, the Netherlands
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Villejuif, France
| | - Lisbeth Rohl
- Department of Radiology, Aarhus University Hospital, Denmark
| | - Philippe Morice
- Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - Nicole Nesvacil
- Department for Radiation Oncology, Medical University of Vienna, Austria
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Villejuif, France
| | | | - Richard Pötter
- Department for Radiation Oncology, Medical University of Vienna, Austria
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, the Netherlands; Department of Radiation Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, The Netherlands
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Chang JH, Jang WI, Kim YB, Kim JH, Kim YS, Kim YS, Park W, Kim J, Yoon WS, Kim JY, Kim HJ. Definitive treatment of primary vaginal cancer with radiotherapy: multi-institutional retrospective study of the Korean Radiation Oncology Group (KROG 12-09). J Gynecol Oncol 2016; 27:e17. [PMID: 26768782 PMCID: PMC4717222 DOI: 10.3802/jgo.2016.27.e17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 09/29/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the outcome of the treatment of primary vaginal cancer using definitive radiotherapy (RT) and to evaluate the prognostic factors of survival. METHODS The medical records of nine institutions were retrospectively reviewed to find the patients with vaginal cancer treated with definitive RT with or without chemotherapy. A total of 138 patients met the inclusion criteria. None had undergone curative excision. RESULTS The median follow-up time of the survivors was 77.6 months and the median survival time was 46.9 months. The 5-year overall survival, cancer-specific survival (CSS), and progression-free survival (PFS) rates were 68%, 80%, and 68.7%, respectively. In the survival analysis, the multivariate analysis showed that a lower the International Federation of Gynecology and Obstetrics (FIGO) stage and prior hysterectomy were favorable prognostic factors of CSS, and a lower FIGO stage and diagnosed prior to year 2000 were favorable prognostic factors of PFS. In the subgroup analysis of the patients with available human papillomavirus (HPV) results (n=27), no statistically significant relationship between the HPV status and recurrence or survival was found. Grade 3 or 4 acute and late toxicity were present in 16 and 9 patients, respectively. The FIGO stage and the tumor size were predictors of severe late toxicity. CONCLUSION The data clearly showed that a higher FIGO stage was correlated with a worse survival outcome and higher severe late toxicity. Therefore, precise RT and careful observation are crucial in advanced vaginal cancer. In this study, the HPV status was not related to the survival outcome, but its further investigation is needed.
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Affiliation(s)
- Ji Hyun Chang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Science, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juree Kim
- Department of Radiation Oncology, Cheil General Hospital & Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Joo-Young Kim
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.
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Gadducci A, Fabrini MG, Lanfredini N, Sergiampietri C. Squamous cell carcinoma of the vagina: natural history, treatment modalities and prognostic factors. Crit Rev Oncol Hematol 2015; 93:211-24. [DOI: 10.1016/j.critrevonc.2014.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/26/2014] [Accepted: 09/25/2014] [Indexed: 10/24/2022] Open
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Hiniker SM, Roux A, Murphy JD, Harris JP, Tran PT, Kapp DS, Kidd EA. Primary squamous cell carcinoma of the vagina: Prognostic factors, treatment patterns, and outcomes. Gynecol Oncol 2013; 131:380-5. [DOI: 10.1016/j.ygyno.2013.08.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/10/2013] [Indexed: 12/12/2022]
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Vaginal cancer. Crit Rev Oncol Hematol 2012; 81:286-95. [DOI: 10.1016/j.critrevonc.2011.04.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 03/21/2011] [Accepted: 04/14/2011] [Indexed: 11/17/2022] Open
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Treatment of locally advanced vaginal cancer with radiochemotherapy and magnetic resonance image-guided adaptive brachytherapy: dose-volume parameters and first clinical results. Int J Radiat Oncol Biol Phys 2011; 82:1880-8. [PMID: 21868174 DOI: 10.1016/j.ijrobp.2011.03.049] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 03/17/2011] [Accepted: 03/31/2011] [Indexed: 12/13/2022]
Abstract
PURPOSE To investigate the clinical feasibility of magnetic resonance image-guided adaptive brachytherapy (IGABT) for patients with locally advanced vaginal cancer and to report treatment outcomes. METHODS AND MATERIALS Thirteen patients with vaginal cancer were treated with external beam radiotherapy (45-50.4 Gy) plus IGABT with or without chemotherapy. Distribution of International Federation of Gynecology and Obstetrics stages among patients were as follows: 4 patients had Stage II cancer, 5 patients had Stage III cancer, and 4 patients had Stage IV cancer. The concept of IGABT as developed for cervix cancer was transferred and adapted for vaginal cancer, with corresponding treatment planning and reporting. Doses were converted to the equivalent dose in 2 Gy, applying the linear quadratic model (α/β = 10 Gy for tumor; α/β = 3 for organs at risk). Endpoints studied were gross tumor volume (GTV), dose-volume parameters for high-risk clinical target volume (HRCTV), and organs at risk, local control (LC), adverse side effects, and survival. RESULTS The mean GTV (± 1 standard deviation) at diagnosis was 45.3 (±30) cm(3), and the mean GTV at brachytherapy was 10 (±14) cm(3). The mean D90 for the HRCTV was 86 (±13) Gy. The mean D2cc for bladder, urethra, rectum, and sigmoid colon were 80 (±20) Gy, 76 (±16) Gy, 70 (±9) Gy, and 60 (±9) Gy, respectively. After a median follow-up of 43 months (range, 19-87 months), one local recurrence and two distant metastases cases were observed. Actuarial LC and overall survival rates at 3 years were 92% and 85%. One patient with Stage IVA and 1 patient with Stage III disease experienced fistulas (one vesicovaginal, one rectovaginal), and 1 patient developed periurethral necrosis. CONCLUSIONS The concept of IGABT, originally developed for treating cervix cancer, appears to be applicable to vaginal cancer treatment with only minor adaptations. Dose-volume parameters for HRCTV and organs at risk are in a comparable range. First clinical results indicate excellent LC. Further prospective multicenter studies are needed to establish this method and to confirm these results.
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Compliance to the prescribed overall treatment time (OTT) of curative radiotherapy in normal clinical practice and impact on treatment duration of counteracting short interruptions by treating patients on Saturdays. Clin Transl Oncol 2009; 11:302-11. [DOI: 10.1007/s12094-009-0358-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Exclusive radiotherapy for primary squamous cell carcinoma of the vagina. Radiother Oncol 2007; 85:362-70. [DOI: 10.1016/j.radonc.2007.09.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 09/19/2007] [Accepted: 09/21/2007] [Indexed: 11/21/2022]
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Tran PT, Su Z, Lee P, Lavori P, Husain A, Teng N, Kapp DS. Prognostic factors for outcomes and complications for primary squamous cell carcinoma of the vagina treated with radiation. Gynecol Oncol 2007; 105:641-9. [PMID: 17363046 DOI: 10.1016/j.ygyno.2007.01.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 01/13/2007] [Accepted: 01/18/2007] [Indexed: 12/27/2022]
Abstract
PURPOSE To analyze the results of treatment and identify prognostic factors for primary squamous cell carcinoma (SCCA) of the vagina managed with radiotherapy at a single institution. MATERIALS AND METHODS Seventy-eight patients were analyzed in this retrospective series. Mean characteristics: follow-up 89 months; age 65 years (range 33-99); tumor size 3.8 cm (0.3-10); treatment hemoglobin 12.4 g/dl (range 8.7-14.4); and tumor dose 72 Gy (range 6-127). In addition, 49% of our cohort had a prior hysterectomy. The FIGO stage distribution: I (42%); II (29%); III (17%); and IVA/B (11%). Sixty-two percent of patients were treated with a combination of external beam radiation (EBRT) and brachytherapy, 22% with EBRT alone and 13% with brachytherapy alone. RESULTS Kaplan-Meier (KM) 5-year pelvic control, distant metastasis free survival and disease specific survival probabilities: stage I, 83%, 100%, and 92%; stage II, 76%, 95%, and 68%; stage III, 62%, 65%, and 44%; and stage IV, 30%, 18%, and 13%. On multivariate analysis: stage; treatment hemoglobin; and prior hysterectomy were prognostic for DSS (p<0.05). The KM 5-year grade 3/4 (G3/4) complication free estimate of our cohort was 84%. G3/4 complications: tumor size and tumor dose were independently predictive (p<0.05). CONCLUSIONS Radiotherapy as a single modality for early stage primary vaginal SCCA produces good results. Advanced stage disease necessitates a combined modality approach and/or new methods. Treatment Hg levels appear to be clinically significant and studies on correction of anemia during treatment are warranted.
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Affiliation(s)
- Phuoc T Tran
- Department of Radiation Oncology, Stanford Cancer Center, 875 Blake Wilbur Drive, Stanford, CA 94305, USA
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Hellman K, Lundell M, Silfverswärd C, Nilsson B, Hellström AC, Frankendal B. Clinical and histopathologic factors related to prognosis in primary squamous cell carcinoma of the vagina. Int J Gynecol Cancer 2006; 16:1201-11. [PMID: 16803507 DOI: 10.1111/j.1525-1438.2006.00520.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The goal of this retrospective study concerning primary carcinoma of the vagina (PCV) was to analyze clinical and histopathologic prognostic factors in one of the largest known material, which comprised 314 patients. PCV is a rare disease, and the majority of published studies are based on small materials; therefore, the established knowledge concerning prognostic factors is insufficient. Routine treatment is based on irradiation with risk for undertreatment or overtreatment, which leads to unnecessary complications in the absence of prognostic factors. The overall 5-year disease-specific survival rate in this study was 45% and in stage I 75%. In the univariate statistical analysis, several factors correlated significantly with disease-specific survival. However, in the multivariate analysis, there were only three factors that independently could predict poor survival-high age at diagnosis, large tumors (> or =4 cm), and advanced stage. Common background factors with no prognostic significance were prior hysterectomy, other gynecological malignancies, and pelvic irradiation. In conclusion, this study has elucidated three strong prognostic factors that might be considered in the choice of therapy and also for modification of the FIGO guidelines. Increased knowledge concerning complementary biologic markers to discriminate between low- and high malignant tumors is however of great importance.
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Affiliation(s)
- K Hellman
- Department of Gynecological Oncology, Radiumhemmet and Department of Hospital Physics, Karolinska University Hospital, S-17176 Stockholm, Sweden.
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Ljungkvist ASE, Bussink J, Kaanders JHAM, Wiedenmann NE, Vlasman R, van der Kogel AJ. Dynamics of Hypoxia, Proliferation and Apoptosis after Irradiation in a Murine Tumor Model. Radiat Res 2006; 165:326-36. [PMID: 16494521 DOI: 10.1667/rr3515.1] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Proliferation and hypoxia affect the efficacy of radiotherapy, but radiation by itself also affects the tumor microenvironment. The purpose of this study was to analyze temporal and spatial changes in hypoxia, proliferation and apoptosis after irradiation (20 Gy) in cells of a murine adenocarcinoma tumor line (C38). The hypoxia marker pimonidazole was injected 1 h before irradiation to label cells that were hypoxic at the time of irradiation. The second hypoxia marker, CCI-103F, and the proliferation marker BrdUrd were given at 4, 8 and 28 h after irradiation. Apoptosis was detected by means of activated caspase 3 staining. After immunohistochemical staining, the tumor sections were scanned and analyzed with a semiautomatic image analysis system. The hypoxic fraction decreased from 22% in unirradiated tumors to 8% at both 8 h and 28 h after treatment (P < 0.01). Radiation did not significantly affect the fraction of perfused vessels, which was 95% in unirradiated tumors and 90% after treatment. At 8 h after irradiation, minimum values for the BrdUrd labeling index (LI) and maximum levels of apoptosis were detected. At 28 h after treatment, the BrdUrd labeling and density of apoptotic cells had returned to pretreatment levels. At this time, the cell density had decreased to 55% of the initial value and a proportion of the cells that were hypoxic at the time of irradiation (pimonidazole-stained) were proliferating (BrdUrd-labeled). These data indicate an increase in tumor oxygenation after irradiation. In addition, a decreased tumor cell density without a significant change in tumor blood perfusion (Hoechst labeling) was observed. Therefore, it is likely that in this tumor model the decrease in tumor cell hypoxia was caused by reduced oxygen consumption.
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Affiliation(s)
- Anna S E Ljungkvist
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Choo JJ, Scudiere J, Bitterman P, Dickler A, Gown AM, Zusag TW. Vaginal lymphatic channel location and its implication for intracavitary brachytherapy radiation treatment. Brachytherapy 2006; 4:236-40. [PMID: 16182225 DOI: 10.1016/j.brachy.2005.02.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2004] [Revised: 01/27/2005] [Accepted: 02/08/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE In vaginal intracavitary brachytherapy using cylindrical applicators, it is common to prescribe dose to a depth of 0.5 cm to cover the lymphatic channels. However, the actual depth of the lymphatics within the vaginal wall has never been determined. In this study, we examined the depth distribution of lymphatics lying beneath the mucosal surface of the vagina. METHODS AND MATERIALS Between January 24, 1996 and October 27, 2003, 31 patients underwent full-thickness vaginal biopsy or partial resection for both benign and malignant disease. In addition, in February 2004, vaginal samples from two autopsy specimens were stretched and pinned for formalin fixation and slide production. Forty-five slides of both stretched and nonstretched vaginal tissue were stained with D2-40 monoclonal antibody lymphatic endothelium marker. The percentages of lymphatics located within 1, 1-2, 2-3, and 3-4mm were calculated for all slides. RESULTS For the nonstretched samples, the percentages of lymphatics located within 1, 1-2, 2-3, and 3-4mm were 50.5%, 30.7%, 11.9%, and 6.9%, respectively. For the stretched samples, the percentages of lymphatics located within 1, 1-2, 2-3, and 3-4mm were 44.0%, 33.8%, 18.8%, and 3.4%, respectively. The differences of lymphatic percentages within and superficial to 1mm (p=0.60), 1-2mm (p=0.85), 2-3mm (p=0.89), and 3-4mm (p=0.99) were not statistically significant between the stretched and nonstretched states. CONCLUSIONS Our results show that approximately 95% of vaginal lymphatic channels are located within a 3mm depth from the vaginal surface. This suggests that dose prescribed to a depth less than 0.5 cm may be adequate and could permit treatment with less normal tissue toxicity in certain clinical situations.
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Affiliation(s)
- Julia J Choo
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA.
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16
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Vuong T, Franco E, Lehnert S, Lambert C, Portelance L, Nasr E, Faria S, Hay J, Larsson S, Shenouda G, Souhami L, Wong F, Freeman C. Silver leaf nylon dressing to prevent radiation dermatitis in patients undergoing chemotherapy and external beam radiotherapy to the perineum. Int J Radiat Oncol Biol Phys 2004; 59:809-14. [PMID: 15183484 DOI: 10.1016/j.ijrobp.2003.11.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2003] [Revised: 11/05/2003] [Accepted: 11/12/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE Silver-leaf nylon dressing (SLND) has been shown to have effective antimicrobial activity and to enhance healing in burns and skin grafts. The purpose of this study was to evaluate the value of SLND in preventing radiation dermatitis in patients undergoing radiotherapy to target volumes that included the perineum and concurrent chemotherapy. METHODS AND MATERIALS Fifteen consecutive patients with either anal canal or gynecologic cancer were offered the SLND as a preventive intervention. The evaluation was based on standardized photographs taken at the end of treatment. A historical control group of 15 patients with the same neoplasms who received standard skin care was assessed in the same fashion. Ten observers unaware of the treatment intervention were enrolled in the evaluation of the skin changes. The Mann-Whitney U test was used to assess the statistical significance of the differences in the dermatitis scores between the two patient groups. RESULTS The mean dermatitis score for controls was 2.62 (standard deviation, 0.48). The mean score for the SLND group was significantly lower at 1.16 (standard deviation, 0.40; p <0.0001). CONCLUSION The results of this study suggest that SLND is effective in reducing radiation dermatitis, apparently because of its antibacterial properties.
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Affiliation(s)
- Té Vuong
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada.
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Kushner DM, Fleming PA, Kennedy AW, Wilkinson DA, Lee E, Saffle PA. High dose rate192Ir afterloading brachytherapy for cancer of the vagina. Br J Radiol 2003; 76:719-25. [PMID: 14512332 DOI: 10.1259/bjr/15634046] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report results of brachytherapy for carcinoma of the vagina, utilizing a Nucletron high dose rate system for Delclos Vaginal Applicators (cylinder) and Syed Template Applicators (interstitial). The linear quadratic (LQ) model was used to determine the optimum time-dose-fractionation schedules. Interstitial doses were determined at the isodose line that included gross tumour. Cylinder doses were determined either at the vaginal surface (5 cases), at 0.5 cm depth (5 cases), or at 1.0 cm depth (1 case). For the first treatment (n=19), interstitial templates were utilized in 8 patients and vaginal cylinders in 11. 11 patients received second treatments: 6 templates and 5 cylinders. The median dose of external beam radiation (n=15) was 40.0 Gy followed, after a median 23 day interval, by high dose rate brachytherapy (HDRB) of 4 fractions in 30-42 h; then a median interval gap of 25 days, followed by repeat HDRB. The median total fractionated HDRB dose per patient was 23.0 Gy (range: 6.9 Gy to 40.4 Gy; calculated low dose rate equivalent of 29.8 Gy). Tumour histologies included 14 squamous cell carcinomas, 2 adenocarcinomas, 2 melanomas, and 1 small cell tumour. Three patients experienced early brachytherapy-related complications (diarrhoea, dysuria and labial dermatitis). Three patients (15.8%) developed serious/late complications including ureteral stenosis, painful vaginal necrosis and small bowel obstruction. The first of these patients received 2 templates, the second a cylinder followed by a template and a cylinder, and the third a single cylinder. The 2 year progression-free survival was 39.3% (median 15.7 months), while the 2 year overall survival was 66.1% (median 29.9 months). (192)Ir afterloading HDRB is a feasible approach to women with vaginal cancer with acceptable toxicity and tumour response. Potential advantages include patient preference, outpatient cost-effectiveness in the case of cylinder technique, and no radiation exposure to hospital personnel. Long-term follow-up is needed to further assess late complications, and larger studies are needed to confirm our results.
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Affiliation(s)
- D M Kushner
- Department of Obstertrics and Gynecology, University of Wisconsin Hospital and Clinics, H4/636 CSC, 600 Highland Avenue, Madison, WI 53792-3236, USA
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18
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, Emory University, and the Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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19
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Kucera H, Mock U, Knocke TH, Kucera E, Pötter R. Radiotherapy alone for invasive vaginal cancer: outcome with intracavitary high dose rate brachytherapy versus
conventional low dose rate brachytherapy. Acta Obstet Gynecol Scand 2002. [DOI: 10.1034/j.1600-0412.2001.080004355.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tjalma WA, Monaghan JM, de Barros Lopes A, Naik R, Nordin AJ, Weyler JJ. The Role of Surgery in Invasive Squamous Carcinoma of the Vagina. Gynecol Oncol 2001; 81:360-5. [PMID: 11371123 DOI: 10.1006/gyno.2001.6171] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to define the role of surgery in managing patients with a primary squamous vaginal cancer. METHODS A retrospective review was conducted of patients with primary invasive vaginal cancer managed at one institution over a 25-year period. The results were compared with those of all major publications of the past 20 years. RESULTS A total of 84 patients were reviewed. Forty-five (66%) were of squamous origin. The median follow-up was 45 months (range: 0.6-268). The patients were primarily treated by surgery in 67% and by radiotherapy alone in 33% of cases. The 5- and 10-year overall survival was, respectively, 74 and 58%. For stage I the figures were 91 and 70%. These survival rates compared favorably with those of published series of cases managed by radiotherapy alone. Univariate analysis showed that age (P = 0.004), size (P = 0.009), site (P = 0.016), lymph node status (P = 0.022), FIGO stage (P = 0.027), and treatment (P = 0.003) were relevant prognostic factors. Multiple regression analysis, however, revealed that only age (P = 0.009) and size (P = 0.037) were independent prognostic variables. CONCLUSIONS Stage I and II squamous vaginal cancer patients have good outcomes in terms of survival and local tumor control if they are managed by initial surgery followed by selective radiotherapy.
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Affiliation(s)
- W A Tjalma
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, NE9 6SX, United Kingdom.
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21
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Kouvaris JR, Kouloulias VE, Plataniotis GA, Balafouta EJ, Vlahos LJ. Dermatitis during radiation for vulvar carcinoma: prevention and treatment with granulocyte-macrophage colony-stimulating factor impregnated gauze. Wound Repair Regen 2001; 9:187-93. [PMID: 11472614 DOI: 10.1046/j.1524-475x.2001.00187.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to determine the effectiveness of granulocyte-macrophage colony-stimulating factor (GM-CSF) impregnated gauze in preventing or healing radiation-induced dermatitis. Sixty-one patients were irradiated for vulvar carcinoma. Thirty-seven applied steroid cream at irradiated areas throughout radiotherapy (Group A) and 24 patients applied additionally GM-CSF impregnated gauze (40 micrcog/cm2 of skin-irradiated area, twice per day) in addition to the steroid cream, after 20 Gy of irradiation (Group B). The score of skin reactions (P=0.008, chi2 test) and the time interval of radiotherapy interruption (P=0.037, Mann-Whitney U test) were statistically significantly reduced in Group B patients. Multivariate analysis of variance showed for this group not only a significant reduction in the Sum of Gross Dermatitis Scoring (P<0.001, adjusted for Duration of Dermatitis) but also a significant reduction of the healing time (P=0.02, adjusted for Sum of Gross Dermatitis Scoring). The pain grading was less (P=0.014, chi2 test) and pain reduction was noticed sooner after the application of GM-CSF impregnated gauze (P=0.0017, Mann-Whitney U test). Multivariate logistic regression analysis showed that the only significant effect on dermatitis score is due to Body Mass Index (P=0.034) and the application of GM-CSF (P=0.008). GM-CSF impregnated gauze can be effective in preventing and healing radiation-induced dermatitis and in reducing the interruption intervals of radiotherapy for vulvar carcinomas.
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Affiliation(s)
- J R Kouvaris
- Aretaieion Hospital, Department of Radiotherapy, University of Athens, Greece.
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22
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Kouvaris JR, Kouloulias VE, Plataniotis GA, Kokakis JD, Vlahos LJ. Topical granulocyte-macrophage colony-stimulating factor for radiation dermatitis of the vulva. Br J Dermatol 2001; 144:646-7. [PMID: 11260045 DOI: 10.1046/j.1365-2133.2001.04115.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Tewari KS, Cappuccini F, Puthawala AA, Kuo JV, Burger RA, Monk BJ, Manetta A, Berman ML, Disaia PJ, Nisar AM. Primary invasive carcinoma of the vagina: treatment with interstitial brachytherapy. Cancer 2001; 91:758-70. [PMID: 11241244 DOI: 10.1002/1097-0142(20010215)91:4<758::aid-cncr1062>3.0.co;2-u] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Because primary carcinoma of the vagina comprises less than 2% of all gynecologic malignancies, the reported experience in the treatment of large numbers of patients is available only from a few major centers and most often encompasses a variety of differences in treatment selection and technique. The objective of this study was to assess the long term results of an interstitial iridium-192 afterloading implant technique using the Syed-Neblett dedicated vaginal plastic template. METHODS Patients who were treated from 1976 to 1997 were examined retrospectively. RESULTS Seventy-one patients underwent interstitial implantation with (n = 61 patients) or without external beam radiotherapy. The median age was 59 years (range, 16-86 years). Patients were staged according to the International Federation of Gynecology and Obstetrics system and included Stage I (n = 10 patients), Perez modification Stage IIA (n = 14 patients), Perez modification Stage IIB (n = 25 patients), Stage III (n = 15 patients), and Stage IV (n = 7 patients). Each implant delivered an approximately 20-gray (Gy) minimum tumor dose, with the total tumor dose reaching 80 Gy with integrated external beam radiotherapy. Local control was achieved in 53 patients (75%). The median follow-up was 66 months (range, 15-163 months), and the 2-year, 5-year, and 10-year actuarial disease free survival rates are 73%, 58%, and 58%, respectively. By stage, 5-year disease free survival rates included Stage I, 100% of patients; Stage IIA, 60% of patients; Stage IIB, 61% of patients; Stage III, 30% of patients; and Stage IV, 0% of patients. The factors disease stage and primary lesion size independently influenced the survival rates. Significant complications occurred in 9 patients (13%) and included necrosis (n = 4 patients), fistulae (n = 4 patients), and small bowel obstruction (n = 1 patient). CONCLUSIONS Interstitial irradiation can effect local control in the majority of patients with primary carcinoma of the vagina with acceptable morbidity. Long term cure is demonstrable in patients with Stage I-III disease.
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Affiliation(s)
- K S Tewari
- The Chao Family National Cancer Institute-Designated Comprehensive Cancer Center, University of California, Irvine Medical Center, Orange, California, USA
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Pingley S, Shrivastava SK, Sarin R, Agarwal JP, Laskar S, Deshpande DD, Dinshaw KA. Primary carcinoma of the vagina: Tata Memorial Hospital experience. Int J Radiat Oncol Biol Phys 2000; 46:101-8. [PMID: 10656380 DOI: 10.1016/s0360-3016(99)00360-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Carcinoma of the vagina is a rare gynecological malignancy comprising approximately 2% of all the gynecological malignancies. We have analyzed the treatment outcome of the patients treated at the Tata Memorial Hospital from January 1984 to December 1993. METHODS AND MATERIALS In this 10-year period, 134 patients of primary vaginal cancers were registered at our hospital. Of these, 75 patients received complete treatment and are analyzed. RESULTS Disease-free survival (DFS) for the whole group is 50%, and overall survival (OAS) is 60%. Most locoregional recurrences and distant failures are noted in the 2 years following treatment. DFS at 5 years is as follows: Stage I (5 patients), Stage IIA (37 patients), Stage IIB (15 patients), Stage III (14 patients), and Stage IV (4 patients); are 40%, 55%, 60%, 50%, and 25%, respectively. The DFS for patients with complete response (42 patients) to external radiation at 5 years is 68%, with partial response (25 patients) is 35%, and with poor or no response (6 patients) is 18% (p = 0.0000). We observed that brachytherapy was an important part of the treatment, and patients who received brachytherapy (59 patients), either with a vaginal intracavitary applicator (30 patients) or interstitial implant (29 patients) had a DFS of 53% and 56%, respectively, while 15 patients who received external radiation alone had a DFS of 30%. Patients receiving brachytherapy within 4 weeks of external radiation had a DFS of 60% as compared to 30% when the interval was more than 4 weeks. CONCLUSION The factors indicating prognosis are: site and extent of involvement, presence of lymph nodes at presentation, technique of brachytherapy, and interval between external radiation and brachytherapy.
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Affiliation(s)
- S Pingley
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, India
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25
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Perez CA, Grigsby PW, Garipagaoglu M, Mutch DG, Lockett MA. Factors affecting long-term outcome of irradiation in carcinoma of the vagina. Int J Radiat Oncol Biol Phys 1999; 44:37-45. [PMID: 10219792 DOI: 10.1016/s0360-3016(98)00530-6] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This report evaluates prognostic and technical factors affecting outcome of patients with primary carcinoma of the vagina treated with definitive radiation therapy. METHODS AND MATERIALS A retrospective analysis was performed on records of 212 patients with histologically confirmed carcinoma of the vagina treated with irradiation. RESULTS Tumor stage was the most significant prognostic factor; actuarial 10-year disease-free survival was 94% for Stage 0 (20 patients), 80% for Stage I (59 patients), 55% for Stage IIA (63 patients), 35% for Stage IIB (34 patients), 38% for Stage III (20 patients), and 0% for Stage IV (15 patients). All in situ lesions except one were controlled with intracavitary therapy. Of the patients with Stage I disease, 86% showed no evidence of vaginal or pelvic recurrence; most of them received interstitial or intracavitary therapy or both, and the addition of external-beam irradiation did not significantly increase survival or tumor control. In Stage IIA (paravaginal extension) and IIB (parametrial involvement) 66% and 56% of the tumors, respectively, were controlled with a combination of brachytherapy and external-beam irradiation; 13 of 20 (65%) Stage III tumors were controlled in the pelvis. Four patients with Stage IV disease (27%) had no recurrence in the pelvis. The total incidence of distant metastases was 13% in Stage I, 30% in Stage IIA, 52% in Stage IIB, 50% in Stage III, and 47% in Stage IV. The dose of irradiation delivered to the primary tumor or the parametrial extension was of relative importance in achieving successful results. In patients with Stage I disease, brachytherapy alone achieved the same local tumor control (80-100%) as in patients receiving external pelvic irradiation (78-100%) as well. In Stage II and III there was a trend toward better tumor control (57-80%) with combined external irradiation and brachytherapy than with the latter alone (33-50%) (p = 0.42). The incidence of grade 2-3 complications (12%) correlated with the stage of the tumor and type of treatment given. CONCLUSION Radiation therapy is an effective treatment for patients with vaginal carcinoma, particularly Stage I. More effective irradiation techniques, including optimization of dose distribution combining external irradiation and interstitial brachytherapy in tumors beyond Stage I, are necessary to enhance locoregional tumor control. The high incidence of distant metastases emphasizes the need for earlier diagnosis and effective systemic cytotoxic agents to improve survival in these patients.
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Affiliation(s)
- C A Perez
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, MO, USA.
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Begg AC, Haustermans K, Hart AA, Dische S, Saunders M, Zackrisson B, Gustaffson H, Coucke P, Paschoud N, Hoyer M, Overgaard J, Antognoni P, Richetti A, Bourhis J, Bartelink H, Horiot JC, Corvo R, Giaretti W, Awwad H, Shouman T, Jouffroy T, Maciorowski Z, Dobrowsky W, Struikmans H, Wilson GD. The value of pretreatment cell kinetic parameters as predictors for radiotherapy outcome in head and neck cancer: a multicenter analysis. Radiother Oncol 1999; 50:13-23. [PMID: 10225552 DOI: 10.1016/s0167-8140(98)00147-9] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE The aim of this study was to assess the potential of pre-treatment cell kinetic parameters to predict outcome in head and neck cancer patients treated by conventional radiotherapy. MATERIALS AND METHODS Data from 11 different centers were pooled. Inclusion criteria were such that the patients received radiotherapy alone, and that the radiotherapy was given in an overall time of at least 6 weeks with a dose of at least 60 Gy. All patients received a tracer dose of either iododeoxyuridine (IdUrd) or bromodeoxyuridine (BrdUrd) intravenously prior to treatment and a tumor biopsy was taken several hours later. The cell kinetic parameters labeling index (LI), DNA synthesis time (Ts) and potential doubling time (Tpot) were subsequently calculated from flow cytometry data, obtained on the biopsies using antibodies against I/BrdUrd incorporated into DNA. Each center carried out their own flow cytometry analysis. RESULTS From the 11 centers, a total of 476 patients conforming to the inclusion criteria were analyzed. Median values for overall time and total dose were 49 days and 69 Gy, respectively. Fifty one percent of patients had local recurrences and 53% patients had died, the majority from their disease. Median follow-up was 20 months; being 30 months for surviving patients. Multivariate analysis revealed that T-stage, maximum tumor diameter, differentiation grade, N-stage, tumor localization and overall time correlated with locoregional control, in decreasing order of significance. For the cell kinetic parameters, univariate analysis showed that only LI was significantly associated with local control (P=0.02), with higher values correlating with a worse outcome. Ts showed some evidence that patients with longer values did worse, but this was not significant (P=0.06). Tpot showed no trend (P=0.8). When assessing survival in a univariate analysis, neither LI nor Tpot associated with outcome (P=0.4, 0.4, respectively). Surprisingly, Ts did correlate with survival, with longer values being worse (P=0.02). In the multivariate analysis of local control, LI lost its significance (P=0.16). CONCLUSIONS The only pretreatment kinetic parameter for which some evidence was found for an association with local control (the best end-point for testing the present hypothesis) was LI, not Tpot, and this evidence disappeared in a multivariate analysis. It therefore appears that pretreatment cell kinetic measurements carried out using flow cytometry, only provide a relatively weak predictor of outcome after radiotherapy in head and neck cancer.
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Affiliation(s)
- A C Begg
- Department of Radiotherapy, The Netherlands Cancer Institute, Amsterdam
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del Charco JO, Bolek TW, McCollough WM, Maria BL, Kedar A, Braylan RC, Mickle JP, Buatti JM, Mendenhall NP, Marcus RB. Medulloblastoma: time-dose relationship based on a 30-year review. Int J Radiat Oncol Biol Phys 1998; 42:147-54. [PMID: 9747832 DOI: 10.1016/s0360-3016(98)00197-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Time-dose relationships have proven important in many cancer sites. This study evaluates the time factors involved in the successful postoperative radiotherapy of medulloblastoma, based on a 30-year experience in a single institution. METHODS AND MATERIALS Fifty-three patients with medulloblastoma received postoperative craniospinal radiotherapy with curative intent between 1963 and 1993. Seven patients (13%) underwent biopsy alone, 28 patients (53%) had subtotal excision, and 18 patients (34%) had gross total excision. Eleven patients received adjuvant chemotherapy. The mean posterior fossa dose was 53.1 Gy; most patients received 54.0 Gy (range, 34.3 to 69.6 Gy). For 41 patients receiving once-a-day therapy, the mean dose was 50.6 Gy (range, 34.3 to 56.0 Gy). For 12 patients receiving twice-a-day therapy, the mean dose was 61.8 Gy (range, 52.6 to 69.6 Gy). Minimum follow-up was 2 years, and median follow-up was 10.7 years. Survival, freedom from relapse, and disease control in the posterior fossa were calculated using the Kaplan-Meier method, and multivariate analysis was performed for prognostic factors. Variables related to radiotherapy were examined, including dose to the craniospinal axis, dose to the posterior fossa, fractionation (once-a-day vs. twice-a-day), use of adjuvant chemotherapy, risk group [high (> or =T3b or > or =M1) or low (< or =T3a and M0-MX)], interval between surgery and radiotherapy (excluding patients receiving chemotherapy before radiotherapy), and duration of radiotherapy. RESULTS At 5 and 10 years, overall survival rates were 68 and 64%, respectively, and freedom-from-relapse rates were 61 and 52%, respectively. Rates of disease control in the posterior fossa at 5 and 10 years were 79 and 68%, respectively. At 5 years, absolute survival rates after biopsy alone, subtotal excision, and gross total excision were 43, 67, and 78%, respectively (p=0.04), and posterior fossa control rates were 27, 89, and 83%, respectively (p=0.004). Duration of the treatment course was the only radiotherapy-related variable with a significant impact on freedom from relapse and posterior fossa control. For patients whose radiation treatment duration was < or =45 days, posterior fossa control was 89% at 5 years, compared with 68% for those treated for >45 days (p=0.01). Duration of treatment also affected freedom from relapse at 5 years: < or =45 days (76%) compared with >45 days (43%), p=0.004. CONCLUSION Our study demonstrates that if adequate doses are used, then radiotherapy treatment duration will significantly affect the outcome in terms of control of disease in the posterior fossa and freedom from relapse. Fractions of at least 1.75 Gy given once a day, or a twice-a-day regimen should yield optimal local control results.
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Affiliation(s)
- J O del Charco
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville 32610-0385, USA
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Hannoun-Lévi JM, Cowen D, Houvenaeghel G, Bladou F, Delpero JR, Resbeut M. Preliminary results of a phase I/II study of post-operative high-dose rate brachytherapy for advanced or recurrent pelvic tumours. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1997; 23:532-7. [PMID: 9484925 DOI: 10.1016/s0748-7983(97)93109-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Electron beam intraoperative radiation therapy (EB-IORT) and intraoperative low-dose rate brachytherapy (IOLB) seem able to improve the local control of advanced or recurrent pelvic tumours (ARPT). We report the usefulness, technical considerations and potential advantages of employing post-operative high-dose rate brachytherapy (POHB) as a treatment for ARPT. From February 1995 to February 1997, 14 patients underwent POHB for ARPT. The mean age was 58 years (range: 37-74). Six patients presented with recurrent rectal carcinoma, three with cervix carcinoma (one primary T3; two recurrences), two with bladder carcinoma (one primary T4; one recurrence), one with prostate carcinoma, one with recurrent pre-sacral lymphoma and one with undifferentiated carcinoma. At the time of resection, blind-end HDR catheters were implanted in a single plan in the tumour bed and stabilized by absorbable sutures. Eight days later, POHB delivered 20Gy in 5 fractions or 40Gy in 10 fractions for advanced and recurrent tumours, respectively. To decrease the incidence of late side-effects, a change was made after the tenth patient to deliver 2 Gy per fraction twice a day, with an interval of 6 h between each fraction. With a median follow-up of 8 months (range: 1-22), local control was achieved in all cases. Six patients developed metastatic disease. One patient presented a perineal wound dehiscence requiring surgery 2 months after POHB. POHB is feasible for patients with recurrent or advanced pelvic diseases, and appears more cost-effective than EB-IORT for dosimetric and radiobiological considerations. Compared with IOLB, POHB allows the total radioprotection of the medical staff, and, in the context of cost reduction, a reduction of the overall time of hospitalization.
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Affiliation(s)
- J M Hannoun-Lévi
- Department of Radiotherapy, Institut Paoli-Calmettes, Marseille, France.
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Kwong DL, Sham JS, Chua DT, Choy DT, Au GK, Wu PM. The effect of interruptions and prolonged treatment time in radiotherapy for nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 1997; 39:703-10. [PMID: 9336153 DOI: 10.1016/s0360-3016(97)00339-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE The effect of interruptions and prolonged overall treatment time in radiotherapy for nasopharyngeal carcinoma and the significance of timing of interruption was investigated. METHODS AND MATERIALS Treatment records of 229 patients treated with continuous course (CC) and 567 patients treated with split course (SC) radiotherapy for nonmetastatic NPC were reviewed. Overall treatment time without inclusion of time for boost was calculated. Treatment that extended 1 week beyond scheduled time was considered prolonged. Outcome in patients who completed treatment "per schedule" were compared with those who had "prolonged" treatment. Because of known patient selection bias between CC and SC, patients on the two schedules were analyzed separately. Multivariate analysis was performed for patients on SC. Total number of days of interruption, age, sex, T and N stage, and the use of boost were tested for the whole SC group. Analysis on the effect of timing of interruption was performed in a subgroup of 223 patients on SC who had a single unplanned interruption. Timing of interruption, either before or after the fourth week for the unplanned interruption, was tested in addition to the other variables in multivariate analysis for this subgroup of SC. RESULTS Twenty-seven (11.8%) patients on CC and 96 (16.9%) patients on SC had prolonged treatment. Patients on SC who had prolonged treatment had significantly poorer loco-regional control rate and disease free survival when compared with those who completed radiotherapy per schedule (p = 0.0063 and 0.001, respectively, with adjustment for stage). For CC, the effect of prolonged treatment on outcome was not significant. The small number of events for patients on CC probably account for the insignificant finding. The number of days of interruption was confirmed as prognostic factor, independent of T and N stages, for loco-regional control and disease-free survival in multivariate analysis for SC. The hazard rate for loco-regional failure increased by 3.3% for each day of interruption. The timing of interruption, at the beginning or towards end of treatment, did not significantly alter outcome. CONCLUSION Interruptions and prolonged treatment adversely affect outcome in radiotherapy for NPC and the effect of repopulation was confirmed. Every effort should be made to keep treatment on schedule and interruptions for whatever reasons should be minimized.
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Affiliation(s)
- D L Kwong
- Department of Radiation Oncology, University of Hong Kong, Queen Mary Hospital, Hong Kong
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Ali MM, Huang DT, Goplerud DR, Howells R, Lu JD. Radiation alone for carcinoma of the vagina: variation in response related to the location of the primary tumor. Cancer 1996; 77:1934-9. [PMID: 8646695 DOI: 10.1002/(sici)1097-0142(19960501)77:9<1934::aid-cncr25>3.0.co;2-#] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A retrospective study of 40 patients with histologically confirmed carcinoma of the vagina is reported. The patients were treated by radiation alone (a combination of external beam therapy and implants) between October 1969 and September 1991 at the Medical College of Virginia Hospital in Richmond. METHODS Thirty-three patients (82%) had squamous cell carcinoma, 2 patients (7%) had adenocarcinoma, and 2 patients (5%) had poorly differentiated cancers (1 melanoma and 1 leiomyosarcoma). The patients were staged according to the International Federation of Gynecology and Obstetrics (FIGO) staging system; there were 13 patients (33%) in Stage 1, 21 (52%) in Stage II, 4 (10%) in Stage III, and 2 (5%) in Stage IV. Thirty-six patients (90%) were treated with external beam therapy and some combination of implant: cylinder, ovoid, or interstitial implants with iodine-125 or iridium-192 (afterloading). Only 4 patients (10%) received treatment by implant only. RESULTS Based on their response, two groups of patients were identified. Group I had 23 patients with tumors predominantly located in the proximal half of the vagina; there were 8 patients in Stage I, 11 in Stage II, 3 in Stage III, and 1 in Stage IV. Of these, three patients failed: one each in Stages III and IV and one Stage II patient was salvaged by surgery. Three patients died due to unrelated causes but with local control. The 5-year actuarial survival in this group was 81%. Group II had 17 patients with tumors located in the mid to distal half of the vagina; there were 5 patients in Stage I, 10 in Stage II, and 2 in Stage IV. Ten patients failed. Eight patients in Stage II had persistent disease, were lost to follow-up, and are presumed dead. Two patients with Stage IV disease also had inadequate local control. The overall actuarial survival in the distal group was 41%, which was significantly worse than the proximal group (81%), at a P value of 0.05. CONCLUSIONS This study discusses the curability of carcinoma of the vagina based on its anatomic location when predominantly similar treatment techniques and radiation doses were applied to either the proximal or the distal part of the vagina, those with cancer in the proximal half had better survival (81%) than those whose cancer was in the distal half (41%).
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Affiliation(s)
- M M Ali
- Department of Radiation Oncology, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond 23298-0058, USA
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Brierley JD, Keane TJ, Cummings B, Hao Y. The absence of an adverse effect of prolongation of radiation treatment of primary rectal adenocarcinoma. Clin Oncol (R Coll Radiol) 1996; 8:97-101. [PMID: 8859606 DOI: 10.1016/s0936-6555(96)80114-2] [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: 02/02/2023]
Abstract
Many reports have shown a deleterious effect from the prolongation of radiation treatment duration on local control of squamous cell carcinomas in a variety of sites. To study whether a similar effect was found in adenocarcinoma of the rectum, a retrospective review was performed of 353 patients treated by external beam radiation therapy for primary adenocarcinoma of the rectum. At 4 years, the local control rate for mobile tumours was 25 percent; for fixed tumours it was 7 percent. By multiple Cox regression analysis, the only factor statistically significant for local control was tumour fixation (P=0.02). Neither treatment length (P=0.44), nor the presence of an interruption in treatment (P=0.41) was significant. The possible explanations for these observations are discussed.
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Affiliation(s)
- J D Brierley
- Princess Margaret Hospital, Toronto, Ontario, Canada
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Fein DA, Lee WR, Lanciano RM, Corn BW, Herbert SH, Hanlon AL, Hoffman JP, Eisenberg BL, Coia LR. Management of extremity soft tissue sarcomas with limb-sparing surgery and postoperative irradiation: do total dose, overall treatment time, and the surgery-radiotherapy interval impact on local control? Int J Radiat Oncol Biol Phys 1995; 32:969-76. [PMID: 7607971 DOI: 10.1016/0360-3016(95)00105-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To evaluate potential prognostic factors in the treatment of extremity soft tissue sarcomas that may influence local control, distant metastases, and overall survival. METHODS AND MATERIALS Sixty-seven patients with extremity soft tissue sarcomas were treated with curative intent by limb-sparing surgery and postoperative radiation therapy at the Fox Chase Cancer Center or the Hospital of the University of Pennsylvania, between October 1970 and March 1991. Follow-up ranged from 4-218 months. The median external beam dose was 60.4 Gy. In 13 patients, interstitial brachytherapy was used as a component of treatment. RESULTS The 5-year local control rate for all patients was 87%. The 5-year local control rate for patients who received < or = 62.5 Gy was 78% compared to 95% for patients who received > 62.5 Gy had larger tumors (p = 0.008) and a higher percentage of Grade 3 tumors and positive margins than patients who received < or = 62.5 Gy. The 5-year local control rate for patients with negative or close margins was 100% vs. 56% in patients with positive margins (p = 0.002). Cox proportional hazards regression analysis was performed using the following variables as covariates: tumor dose, overall treatment time, interval from surgery to initiation of radiation therapy, margin status, grade, and tumor size. Total dose (p = 0.04) and margin status (p = 0.02) were found to significantly influence local control. Only tumor size significantly influenced distant metastasis (p = 0.01) or survival (p = 0.03). CONCLUSION Postoperative radiation therapy doses > 62.5 Gy were noted to significantly improve local control in patients with extremity soft tissue sarcomas. This is the first analysis in the literature to demonstrate the independent influence of total dose on local control of extremity soft tissue sarcomas treated with adjuvant postoperative irradiation.
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Affiliation(s)
- D A Fein
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
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