Association of bladder dose with late urinary side effects in cervical cancer high-dose-rate brachytherapy

Evaluation of plan quality, safety, and toxicity of brachytherapy for locally advanced cervical cancer in an Australian setting following changes in prescription and applicator design

INTRODUCTION

Chemoradiotherapy with MRI-guided brachytherapy boosts is the standard of care for locally advanced cervical cancer. Data from the RetroEMBRACE and EMBRACE I trials provide dose-response curves for target volumes and OAR. This study evaluated plan quality, safety and toxicity following escalation of the CTV_HR D90 prescription from 80-90 Gy to 85-95 Gy for two different applicator designs.

METHODS

A retrospective dosimetric plan quality review was undertaken for consecutively treated locally advanced cervical cancer brachytherapy boosts between 2017 and 2022, and the relationships between implant total reference air kerma (TRAK), CTV_HR volume and vaginal dose were investigated. Safety and ≤grade 3 toxicity results were evaluated.

RESULTS

Seventy patients were identified. All patients received a CTV_HR D90 dose >85 Gy and rectum D2cm3 of <75 Gy, while 88.6% of patients received a bladder D2cm3 <90 Gy. Needles were used in 48.6% of patients, and the mean percentage needle TRAK was 38.2%. Increasing the percentage of needle TRAK decreased vaginal TRAK. Sixty-three patients had more than 12 months of follow-up (median 27 months). From this cohort, grade 3 or higher toxicity for vaginal, genitourinary, gastrointestinal and fistula events were seen in 3.2%, 1.6%, 0% and 3.2% of patients, respectively.

CONCLUSION

Increased dose prescriptions and a change of applicator design were successfully adopted into an Australian practice. Applicator design and interstitial needle use affect the plan quality and ability to meet OAR dose constraints following target dose escalation. No safety concerns with needle use or dose escalation were identified.

Contouring of emerging organs-at-risk (OARS) of the female pelvis and interobserver variability: A study by the Italian association of radiotherapy and clinical oncology (AIRO)

Purpose

To provide straightforward instructions for daily practice in delineating emerging organs-at-risk (OARs) of the female pelvis and to discuss the interobserver variability in a two-step multicenter study.

Methods and materials

A contouring atlas with anatomical boundaries for each emerging OAR was realized by radiation oncologists and radiologists who are experts in pelvic imaging, as per their knowledge and clinical practice. These contours were identified as quality benchmarks for the analysis subsequently carried out. Radiation oncologists not involved in setting the custom-built contouring atlas and interested in the treatment of gynecological cancer were invited to participate in this 2-step trial. In the first step all participants were supplied with a selected clinical case of locally advanced cervical cancer and had to identify emerging OARs (Levator ani muscle; Puborectalis muscle; Internal anal sphincter; External anal sphincter; Bladder base and trigone; Bladder neck; Iliac Bone Marrow; Lower Pelvis Bone Marrow; Lumbosacral Bone Marrow) based on their own personal knowledge of pelvic anatomy and experience. The suggested OARs and the contouring process were then presented at a subsequent webinar meeting with a contouring laboratory. Finally, in the second step, after the webinar meeting, each participant who had joined the study but was not involved in setting the benchmark received the custom-built contouring atlas with anatomical boundaries and was requested to delineate again the OARs using the tool provided. The Dice Similarity Coefficient (DSC) and the Jaccard Similarity Coefficient (JSC) were used to evaluate the spatial overlap accuracy of the different volume delineations and compared with the benchmark; the Hausdorff distance (HD) and the mean distance to agreement (MDA) to explore the distance between contours. All the results were reported as sample mean and standard deviation (SD).

Results

Fifteen radiation oncologists from different Institutions joined the study. The participants had a high agreement degree for pelvic bones sub-structures delineation according to DICE (IBM: 0.9 ± 0.02; LPBM: 0.91 ± 0.01). A moderate degree according to DICE was showed for ovaries (Right: 0.61 ± 0.16, Left: 0.72 ± 0.05), vagina (0.575 ± 0.13), bladder sub-structures (0.515 ± 0.08) and EAS (0.605 ± 0.05), whereas a low degree for the other sub-structures of the anal-rectal sphincter complex (LAM: 0.345 ± 0.07, PRM: 0.41 ± 0.10, and IAS: 0.4 ± 0.07).

Conclusion

This study found a moderate to low level of agreement in the delineation of the female pelvis emerging OARs, with a high degree of variability among observers. The development of delineation tools should be encouraged to improve the routine contouring of these OARs and increase the quality and consistency of radiotherapy planning.

The effect of lower urinary tract substructure doses on side effects of cervical cancer image-guided adaptive brachytherapy

OBJECTIVE

Image-Guided Adaptive Brachytherapy (IGABT) provides a survival advantage in locally advanced cervical cancer (LACC). Although side effects are seen less with this technique, dose parameters that cause urinary side effects are still questionable. We aim to investigate whether the radiotherapy doses of the lower urinary tract substructures (LUSS) affect the urinary system side effects (USSE) of cervical cancer external beam radiotherapy (EBRT) and the IGABT.

METHODS

LUSS (bladder, trigone, bladder neck, and urethra) doses were calculated in 40 patients diagnosed with LACC and receiving primary EBRT, IGABT, and concomitant chemotherapy. D0.1cc, D2cc, and D50% values were examined by contouring the bladder, trigone, bladder neck, and urethra from the intracavitary BT planning computed tomography (CT) images taken every 4 BT fractions, retrospectively. Besides, late USSE (urgency, dysuria (recurrent), frequency, obstruction, incontinence, hematuria, fistula, cystitis) were queried and categorized according to Common Toxicity Criteria for Adverse Events version 5.0.

STATISTICAL ANALYSIS USED

The Chi-square and Fisher's exact tests, Mann-Whitney U-test.

RESULTS

For the whole study population, for both incontinence and dysuria, trigone (D50%), urethra (D50%, D0.1cc,), and bladder neck (D50%, D0.1cc, D2cc) volume and hot spot doses remained significant. For cystitis, urethra (D50%, D0.1cc,) and bladder neck doses (D0.1cc, D50%, D2cc) are worth investigating.

CONCLUSIONS

Although USSE is less common in the intensity-modulated radiation therapy and IGABT era, it may be meaningful to take the doses of LUSS into account when planning IGABT. In addition, delineation of LUSS using only CT seems feasible. More proof is needed to determine delineation technique and dose constraints for LUSS for IGABT.

A qualitative exploration of the spiritual wellbeing of women with advanced cervical cancer in Ghana

BACKGROUND

Spiritual wellbeing is one of the most important aspects of human health, alongside physical, psychological and social factors. Religiosity/spirituality can play a critical role in the lives of people experiencing life-threatening illnesses, such as cervical cancer. Most women with cervical cancer in Africa, including Ghana, are diagnosed at the advanced stage. These women lean on their spiritual connections for strength during their illness. Despite the fact that numerous studies have been conducted on the relevance of religiosity/spirituality in the experience of cancer in other jurisdictions, the same cannot be said about Ghana. The study aims to fill this gap in the literature.

AIM

To explore the spiritual wellbeing of women diagnosed with advanced cervical cancer in Ghana.

METHOD

A qualitative explorative design was employed, with purposive sampling used to recruit 15 women with advanced cervical cancer from a cancer treatment centre of a teaching hospital in Ghana. Individual face-to-face interviews, lasting between 45-90 minutes, were used to gather information. Interviews were audio taped with participants' consent. Data were analysed using thematic content analysis.

FINDINGS

The following sub-themes were identified within one overarching theme of the spiritual wellbeing of women with advanced cervical cancer: the meaning of illness and acceptance; a sense of hope and religiosity; uncertainty; and the will to live.

CONCLUSION

Many participants believed they were bewitched, and the devil was responsible for their cervical cancer. Healthcare providers should adopt a multi-disciplinary approach and widen their care strategies to include spirituality, to enhance the treatment outcomes of women living with advanced cervical cancer.

Influence of icariin on inflammation, apoptosis, invasion, and tumor immunity in cervical cancer by reducing the TLR4/MyD88/NF-κB and Wnt/β-catenin pathways

Background

Cervical cancer is a type of the most common gynecology tumor in women of the whole world. Accumulating data have shown that icariin (ICA), a natural compound, has anti-cancer activity in different cancers, including cervical cancer. The study aimed to reveal the antitumor effects and the possible underlying mechanism of ICA in U14 tumor-bearing mice and SiHa cells.

Methods

The antitumor effects of ICA were investigated in vivo and in vitro. The expression of TLR4/MyD88/NF-κB and Wnt/β-catenin signaling pathways were evaluated.

Results

We found that ICA significantly suppressed tumor tissue growth and SiHa cells viability in a dose-dependent manner. Also, ICA enhanced the anti-tumor humoral immunity in vivo. Moreover, ICA significantly improved the composition of the microbiota in mice models. Additionally, the results clarified that ICA significantly inhibited the migration, invasion capacity, and expression levels of TGF-β1, TNF-α, IL-6, IL-17A, IL-10 in SiHa cells. Meanwhile, ICA was revealed to promote the apoptosis of cervical cancer cells by down-regulating Ki67, survivin, Bcl-2, c-Myc, and up-regulating P16, P53, Bax levels in vivo and in vitro. For the part of mechanism exploration, we showed that ICA inhibits the inflammation, proliferation, migration, and invasion, as well as promotes apoptosis and immunity in cervical cancer through impairment of TLR4/MyD88/NF-κB and Wnt/β-catenin pathways.

Conclusions

Taken together, ICA could be a potential supplementary agent for cervical cancer treatment.

Urinary diversion after pelvic exenteration for gynecologic malignancies

Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B12 deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.

Importance of the ICRU bladder point dose on incidence and persistence of urinary frequency and incontinence in locally advanced cervical cancer: An EMBRACE analysis

PURPOSE

To identify patient- and treatment-related risk factors and dose-effects for urinary frequency and incontinence in locally advanced cervical cancer (LACC) treated with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT).

MATERIAL AND METHODS

Physician-assessed (CTCAE) and patient-reported (EORTC) frequency and incontinence recorded in the EMBRACE-I study were analysed. Risk factors analysis was performed in patients without bladder infiltration and with baseline morbidity available. Cox regression was used for CTCAE grade (G) ≥ 3 and G ≥ 2 and for EORTC "very much" and "quite a bit" or worse. Logistic regression was used for late persistent morbidity defined when CTCAE G ≥ 1 or EORTC ≥ "quite a bit" were scored in at least half of follow-ups.

RESULTS

Longitudinal data on 1153 and 884 patients were available for CTCAE and EORTC analysis, respectively. Median follow-up was 48[3-120] months. Crude incidence rates of G≥2 were 13% and 11% for frequency and incontinence, respectively. Baseline morbidity and overweight-obesity were risk factors for both symptoms. Elderly patients were at higher risk for incontinence. Patients receiving conformal-radiotherapy were at higher risk for frequency. ICRU bladder point (ICRU-BP) dose was a stronger predictor for incontinence than bladder D_2cm3. The 5-year actuarial estimate of G ≥ 2 incontinence increased from 11% to 20% with ICRU-BP doses > 75 Gy compared to ≤ 65 Gy. Frequency showed weaker associations with dose.

CONCLUSION

ICRU-BP dose, in addition to clinical parameters, is a risk factor for urinary incontinence and shows a dose-effect after radio(chemo)therapy and IGABT. ICRU-BP dose should be monitored during treatment planning alongside volumetric parameters. Frequency seems associated with larger irradiated volumes.

A case report of a patient with bulky uterine cervical neoplasm who achieved complete response with "intentional internal high-dose policy" high-dose-rate interstitial brachytherapy

RATIONALE

Gynecological high-dose-rate (HDR) brachytherapy has progressed for years, but it remains difficult for bulky tumors to be controlled locally. Dose limitations to organs at risk (OARs) are invariably obstacles in increasing the prescription dose. Additionally, it is controversial that the excessive hyperdose sleeve, the volume receiving a dose equal to or greater than twice the reference dose, should be eliminated in gynecological HDR brachytherapy. On the other hand, the technique of simultaneous integrated protection was reported for large hepatocellular carcinoma treatment, and similarly, internal high-dose brachytherapy could be used for treating bulky cervical carcinoma.

PATIENT CONCERNS

A 54-year-old female had irregular genital bleeding and lost 13 kg in one year.

DIAGNOSIS

She was diagnosed with T3bN1M0 cervical cancer in another hospital. The transverse diameter of the primary tumor was 10.5 cm.

INTERVENTIONS

The whole pelvis and para-aortic lymph node were irradiated with a total of 50 Gy in 25 fractions, but the size of the tumor showed only a slight decrease to 8.9 cm. After external beam radiotherapy, first-time high-dose-rate interstitial brachytherapy (HDR-ISBT) was administered without "intentional internal high-dose (IIHD) policy," the technique of high-dose administration to only the inside of the tumor. Considering the rectum dose limitation, in the additional 2 times of brachytherapy, "IIHD policy" HDR-ISBT was applied. In the second and third HDR-ISBT, the percentage of the volume exposed to 200% of the prescribed dose for high-risk clinical target volume increased by 241% and 204% compared with the first HDR-ISBT, while the doses to OARs were not significantly higher than those of the first-time HDR-ISBT.

OUTCOMES

Complete response was obtained, and no recurrence findings and side effects caused by HDR-ISBT have been detected for 2 years and 9 months.

LESSONS

To our knowledge, this is the first report of IIHD HDR-ISBT for bulky cervical cancer. This technique can be the solution for treating bulky cervical cancer.