Pattern of failure and long-term morbidity in patients undergoing postoperative radiotherapy for cervical cancer

MR guided high intensity focused ultrasound (MRgHIFU) for treating recurrent gynaecological tumours: a pilot feasibility study

OBJECTIVE

To assess the feasibility of targeting recurrent gynaecological tumours with MR guided high intensity focused ultrasound (MRgHIFU).

METHODS

20 patients with recurrent gynaecological tumours were prospectively scanned on a Philips/Profound 3 T Achieva MR/ Sonalleve HIFU system. Gross tumour volume (GTV) and planning target volume (PTV) were delineated on T 2W and diffusion-weighted imaging (DWI). Achievable treatment volumes that (i) assumed bowel and/or urogenital tract preparation could be used to reduce risk of damage to organs-at-risk (TVoptimal), or (ii) assumed no preparations were possible (TVno-prep) were compared with PTV on virtual treatment plans. Patients were considered treatable if TVoptimal ≥ 50 % PTV.

RESULTS

11/20 patients (55%) were treatable if preparation strategies were used: nine had central pelvic recurrences, two had tumours in metastatic locations. Treatable volume ranged from 3.4 to 90.3 ml, representing 70 ± 17 % of PTVs. Without preparation, 6/20 (30%) patients were treatable (four central recurrences, two metastatic lesions). Limiting factors were disease beyond reach of the HIFU transducer, and bone obstructing tumour access. DWI assisted tumour outlining, but differences from T 2W imaging in GTV size (16.9 ± 23.0%) and PTV location (3.8 ± 2.8 mm in phase-encode direction) limited its use for treatment planning.

CONCLUSIONS

Despite variation in size and location within the pelvis, ≥ 50 % of tumour volumes were considered targetable in 55 % patients while avoiding adjacent critical structures. A prospective treatment study will assess safety and symptom relief in a second patient cohort.

ADVANCES IN KNOWLEDGE

Target size, location and access make MRgHIFU a viable treatment modality for treating symptomatic recurrent gynaecological tumours within the pelvis.

[Ureteral stricture as a late complication of radiotherapy : Possible treatment options]

Ureteral strictures are uncommon complications of radiotherapy which are often recognized late. Their consequences range from harmless dilatation of the ureter to loss of renal function and potential life-threatening urosepsis.Therapy of radiogenic ureteral stricture is a challenging task for every urologist. Several surgical strategies including minimally invasive procedures, reconstruction and partial or complete replacement of the ureter are available.This article provides an overview of the various options in the treatment of radiogenic stricture of the ureter, focusing on the use of ileum and colon segments for ureteral substitution.

Primary surgical management with tailored adjuvant radiation for stage IB2 cervical cancer

OBJECTIVE

To examine the outcome for patients with stage IB2 cervical cancer treated primarily with radical hysterectomy, and to determine the need for adjuvant therapy, the sites of recurrence, and the morbidity of the treatment.

METHODS

We reviewed our experience with 93 patients with stage IB2 cervical cancer treated with primary surgery at the Royal Hospital for Women in Sydney from 1988 to 2008. All patients underwent radical hysterectomy and pelvic lymphadenectomy. If bulky positive nodes were encountered, they were resected without complete lymphadenectomy. Postoperative radiation was tailored to the histologic findings.

RESULTS

The mean age of the patients was 46 years, and 70% had squamous cell carcinomas. Tumor invaded into the outer third of the cervical stroma in 73 cases (78.5%), occult parametrial extension occurred in 15 cases (16.1%), and vascular space invasion occurred in 65 cases (69.9%). Positive pelvic nodes were present in 42 patients (45.2%) and bulky positive para-aortic nodes were present in 5 patients (5.4%). Some type of postoperative adjuvant (chemoradiation) radiation was given to 74 patients (79.6%). With a median follow-up of 96 months, the overall 5-year survival was 80.7%, being 85% for patients with negative nodes and 75% for those with positive nodes (hazard ratio 2.63, 95% confidence interval 1--5.6; P=.045). The major long-term surgical morbidity was lymphedema, which occurred in eight patients (8.6%). Serious long-term radiation morbidity (Radiation Therapy Oncology Group grade 3) occurred in three patients (3.2%).

CONCLUSIONS

Primary radical hysterectomy with tailored postoperative adjuvant radiation for patients with stage IB2 cervical cancer provides good survival with acceptably low morbidity.

LEVEL OF EVIDENCE

III.

Up-to-date management of lymph node metastasis and the role of tailored lymphadenectomy in cervical cancer

Lymph node metastasis (LNM), together with parametrial infiltration and positive surgical margins, is an important prognostic factor in cervical cancer. The incidence of LNM increases with International Federation of Gynecology and Obstetrics (FIGO) stage, with rates being 12%-22% in stage Ib, 10%-27% in stage IIa, and 34%-43% in stage IIb. Radical hysterectomy and pelvic lymphadenectomy are widely used treatments for early-stage (Ib to IIa) cervical cancer, as well as for stage IIb disease, in some European and Asian countries. In several types of cancer, the therapeutic significance of systematic lymphadenectomy has been demonstrated by recent reports showing that a larger number of lymph nodes removed relates to better survival. In cervical cancer, a significant relationship between the number of lymph nodes removed and disease-free survival has been reported in node-positive patients. Preoperative evaluation of nodal status with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) imaging techniques is not sensitive enough to replace the histological examination of dissected nodes. The sentinel node procedure may be an alternative to systematic lymphadenectomy to reduce treatment-related morbidity, but more work on this is needed. Although the presence of LNM does not change FIGO staging, it will modulate postoperative therapy. Progression-free and overall survivals were significantly improved by the addition of chemotherapy to adjuvant radiotherapy after radical hysterectomy and lymphadenectomy. Adjuvant chemotherapy combined solely with radical hysterectomy and systematic lymphadenectomy may also provide a survival benefit. In conclusion, efforts to establish more tailored surgical strategies, by introducing advanced imaging technologies and molecular diagnostic procedures, are needed for cervical cancer.