Hemostatic radiotherapy in carcinoma of the uterine cervix

Objective: To evaluate the treatment of hemorrhagic carcinoma of the uterine cervix with hemostatic radiotherapy (external and intracavitary radiotherapy). Method: Twenty cases of refractory hemorrhagic carcinoma of the uterine cervix receiving hemostatic radiotherapy between April 1987 and May 1992 were analyzed. The age of the patients ranged between 30 and 60 years with a median of 42 years. Results: The mean tumor volume was 130 mm³; all cases were classified as FIGO stage IIb (n = 8), IIIb (n = 11) or IVa (n = 1). Radiotherapy was carried out either by the external or intracavitary technique. The control of hemorrhage was 100% within 12–48 h after radiotherapy. However 85% of patients failed locally in the form of residual, recurrent pelvic or metastatic disease, within 24 months of follow-up. Conclusion:Hemorrhagic cervical cancer has a poor prognosis.     

Pretreatment tumor diameter/volume and pelvic lymph node status assessed by magnetic resonance imaging for uterine cervical carcinoma treated with concurrent chemotherapy and radiotherapy

Aim:  The aim is to evaluate the prognostic value of tumor diameter, volume and pelvic lymph node status assessed by magnetic resonance imaging (MRI) in patients with uterine cervical carcinoma patients treated with concurrent chemotherapy and radiotherapy.
Methods:  Ninety-eight patients diagnosed with stage IB to IIIB cervical carcinoma were entered into the study. Tumor diameter was evaluated in T2-weighted image. The tumor volume was calculated by the equation (volume = width × length × height × π/6) as an ellipsoid approximation. Univariate and multivariate analyses were performed to identify the prognostic factors for overall survival (OS), disease-free survival (DFS), pelvic control (PC) and distant metastasis-free survival (DMFS).
Results:  The 5-year OS, DFS, PC and DMFS rate were 59.8%, 57.3%, 67.9% and 78.8%, respectively. Using univariate analyses, large MRI tumor diameter (≥4 cm), large tumor volume (≥30 mL), pelvic enlarged pelvic lymph nodes, large clinical diameter (≥4 cm) and International Federation of Gynecology and Obstetrics (FigO) stage showed a statistically significantly unfavorable influence on OS and DFS. In multivariate analyses, large tumor volume affected OS, DFS, PC and DMFS, and enlarged pelvic lymph nodes also affected OS.
Conclusion:  Tumor volume and enlarged pelvic lymph nodes determined by pretreatment MRI examinations were significant prognostic factors for patients with invasive cervical carcinoma treated with concurrent chemotherapy and radiotherapy.     

Small cell carcinoma of the cervix: a case report

Small cell carcinoma of the uterine cervix accounts for 1–3% of all cervix cancers. It is an aggressive disease with a poor prognosis. To date, no effective treatment protocol has been determined. Surgery, radiotherapy, and chemotherapy have been used either alone or in combination. Recent data suggests that survival in patients with early staged small cell carcinoma of the cervix is better with surgery combined with chemo-radiotherapy. Here, we presented two patients with stage IB1 small cell carcinoma of the uterine cervix. For both patients, definitive surgery was performed with pelvic and para-aortic lymphadenectomy. Subsequently, they were treated with pelvic external radiotherapy and high-dose-rate intracavitary brachytherapy with concurrent cisplatin based chemotherapy. They were alive with no evidence of disease at 91 and 65 months, respectively.     

Long-term outcome and prognostic factors in patients with cervical carcinoma: a retrospective study

This study evaluates treatment outcomes and possible prognostic factors of inoperable cervical cancer patients treated with external beam radiotherapy (EBRT) and high-dose rate brachytherapy (HDR BRT). Between 1993 and 2000, 183 patients with cervical cancer were treated at our institute. Radiotherapy was the sole treatment modality until January 1997; after the announcement of National Cancer Institute in 1999, 40 mg/m(2) of cisplatin (49%) was routinely applied every week. Median age was 54 years (32-92 years). Most patients (88%) had advanced-stage disease (IIB-IIIB). With a median follow-up time of 45 months (6-121 months), the 5-year overall survival (OS), local recurrence-free survival, disease-free survival (DFS), and distant metastasis-free survival (DMFS) rates were 55%, 71%, 51%, and 77%, respectively. Univariate analysis revealed that age, tumor size, lymph node status, and concomitant cisplatin were prognostic factors for OS. The DFS rates were lower in young age group. Patients with tumor greater than 4 cm and age greater than 40 were at greater risk for local recurrence. Distant metastases were more frequent in patients with adenocarcinoma. Concurrent cisplatin use increases DMFS rates (91% vs 78%; P= 0.05). In multivariate analysis, extensive stage, parametrial infiltration, young age, adenocarcinoma histopathology, and lymph node metastasis were negative prognostic factors for OS while concomitant cisplatin increases OS. Likewise, patients with extensive stage, adenocarcinoma, and without concurrent cisplatin administration had more risk for distant metastasis. There was no treatment-related mortality. Grade 3-4 morbidity rates were seen only in eight patients (4%). The combination of EBRT and HDR BRT together with concomitant chemotherapy in the treatment of locally advanced carcinoma of cervix is safe and well tolerated with acceptable morbidity.     

High dose rate intracavitary brachytherapy for recurrent or residual lesions in the vaginal cuff: Results in post-hysterectomy patients with carcinoma of the cervix

Abstract. Ogino I, Kitamura T, Okamoto N, Nakayama H, Matsubara S. High dose rate intracavitary brachytherapy for recurrent or residual lesions in the vaginal cuff: results in post-hysterectomy patients with carcinoma of the cervix.
The purpose of this study was to assess the long-term survival, disease control, and complication rates of high dose rate intracavitary brachytherapy (HDR-ICR) alone or combined with external beam irradiation (HDR-ICR + EBRT) in patients with pathologically involved or close surgical margin in the vagina (Group 1) and recurrent lesions in the vaginal cuff (Group 2) following hysterectomy for cervical carcinoma. In Group 1, 10 patients received HDR-ICR only, and 11 patients received HDR-ICR + EBRT with or without paravaginal shielding. In Group 2, 8 patients received HDR-ICR only, and 11 patients received HDR-ICR + EBRT with or without paravaginal shielding. The HDR-ICR dose per fraction planned at the Apical Vaginal Point was 5–6 Gy per week. In Group 1, the 5-year absolute survival rates (AS), disease-free survival rates (DFS), and vaginal control rates (VC) were 81.0%, 76.2%, and 100%, respectively. The 5-year AS was lower in patients with parametrial infiltration or adenocarcinoma. In Group 2, the 5-year AS, DFS, and VC were 73.3%, 77.4% and 88.8%, respectively. The 5-year AS was lower when tumors were larger than 3 cm or infiltrated. Late complications occurred in 10 patients. In all but one patient, the complications were acceptable. All patients with cystitis, ileus, or leg edema received EBRT + HDR-ICR.
We recommend a treatment regimen of 25–30 Gy of HDR-ICR alone for Group 1 patients without pathologically high risk of recurrence or Group 2 patients with superficial recurrent lesions, and a treatment regime of 50 Gy whole pelvis EBRT combined with 10–15 Gy HDR-ICR for Group 1 patients with pathologically high risk of recurrence or Group 2 patients with infiltrated recurrent lesions.     

Ⅱb~Ⅲ期宫颈癌264例疗效及预后因素分析

目的探讨Ⅱb~Ⅲ期宫颈癌患者的疗效及预后相关因素。方法分析2007年3月至2008年10月辽宁省肿瘤医院收治的264例宫颈癌患者的临床资料。结果 264例患者的中位随访时间75个月,2、5年总生存率(overall survival,OS)分别为77.7%、65.5%。2、5年肿瘤特异性生存率(disease-specific survival,DSS)分别为78.1%、66.5%。2、5年无病生存率(disease-free survival,DFS)分别为72.7%、64.2%。单因素分析显示,影响OS、DSS、DFS的因素有临床分期(Ⅱb期与Ⅲ期,P0.01),肿瘤大小(4 cm、4~6 cm、6 cm,P0.01)、病理类型(鳞癌与腺癌,P0.01)、阴道受侵范围(无、上1/3、中1/3、下1/3,P0.01)、淋巴结情况(盆腔腹主阴性、仅盆腔阳性、盆腔腹主阳性、未做CT,P0.01)、最低血红蛋白(110 g/L、95~110 g/L、75~95 g/L、52~75 g/L,P0.01)。入院血红蛋白是DFS的影响因素。多因素分析显示,临床分期、病理类型、淋巴结情况、治疗方式、最低血红蛋白为宫颈癌OS、DSS和DFS的独立预后因素。结论Ⅲ期、腺癌、淋巴结阳性、单纯放疗以及最低血红蛋白75 g/L的宫颈癌患者预后不良。     

Prognostic factors in stage IB-IIA cervical carcinomas treated with postoperative radiotherapy.

PURPOSE: This study investigated the prognostic significance of age, stage, tumor size, pelvic lymph node metastasis (PLM), surgical margin invasion, overall radiotherapy time (ORT), and interval between radiotherapy and surgery (IRS) in stage IB-IIA cervical carcinoma. METHOD AND MATERIALS: 100 patients treated with radical hysterectomy and postoperative radiotherapy were evaluated retrospectively. RESULTS: The 5-yr overall survival (OS), disease-free survival (DFS), and pelvic control rate (PC) were 83.6%, 82.8%, and 91.8%, respectively. PLM (p=0.008), IRS (p=0.01), ORT (p=0.007), and tumor size (p=0.028) were found to be significant on PC. PLM (p=0.04), ORT (p=0.04), and IRS (p=0.001) were significant on OS. PLM was significant (p=0.04) and IRS was marginally significant (p=0.06) on DFS. After multivariate analysis, PLM was significant on OS, DFS and PC. Recurrences were seen in 14 patients. CONCLUSION: According to this study PLM, IRS, and ORT are the most important prognostic factors. Recurrences outside the radiation volume leads to treatment failure.     

Treatment results in carcinoma of the cervix stage IB in a total population

A total of 709 patients with stage IB squamous cell carcinoma of the cervix were treated 1967/1972. In 20 cases primary surgery with radical hysterectomy and pelvic lymphadenectomy was performed, 542 received preoperative intracavitary radium treatment, and 147 received intracavitary and external irradiation. The 5-year survival rate for the operated patients was 86% as compared to 82% for the 131 who received a full course of radiotherapy. The distribution of recurrences and the frequency of fistulas was the same in these two groups.     

Prostaglandin-induced cervical dilatation prior to intracavitary radiotherapy for carcinoma of the cervix: a pilot study

The efficacy of 1 mg 16,16-dimethyl-trans-Δ2 prostaglandin E1 (Gemeprost) pessaries in achieving cervical dilatation prior to intracavitary brachytherapy was investigated in 16 post-menopausal women with cervical carcinoma. All had received external beam pelvic radiotherapy in the preceding 6 weeks. Four patients were nulliparous and 12 multiparous (mean parity 1.9). FIGO stages were IB (2), IIA (4), IIB (5), IIIA (1), IIIB (3), IVB (1). The cervical os was assessed before pessary insertion and again at the time of intracavitary insertion. The os was closed in 100% (16/16) of patients before and open in 75% (12/16) of patients after pessary insertion. The maximum size of Hegar dilator passed without mechanical dila-tation was recorded. Mean cervical dilatation was 4.25 H (5.5 H in those with a clinical response). The 12 responding patients had rapid and uncomplicated procedures with no need for additional mechanical dilatation. Both patients in whom attempted mechanical dilatation failed had had previous conization of the cervix. The following mild side-effects were reported: abdominal cramps (43.8%), headache (12.5%) and fever (6.3%). These data support the use of Gemeprost pessaries to achieve cervical dilatation in post-menopausal women undergoing intracavitary brachy-therapy following external beam radiotherapy.     

The role of interstitial brachytherapy using template in locally advanced gynecological malignancies

OBJECTIVE: Brachytherapy plays a major role in the treatment of patients with carcinoma of the cervix. However, routine intracavitary brachytherapy may not be feasible or adequate to treat locally advanced disease. The purpose of this prospective study was to assess treatment outcome for patients with locally advanced gynecological malignancies treated with interstitial brachytherapy using Martinez Universal Perineal Interstitial Template (MUPIT) and to study the acute and late sequelae after treatment by this technique. METHODS: Thirty previously untreated patients with histologically confirmed carcinoma of the cervix (20 patients), vault (7 patients), and vagina (3 patients) were treated by a combination of external beam radiotherapy using megavoltage irradiation to the pelvis to a dose of 4000 to 5000 cGy followed by interstitial brachytherapy using MUPIT between June 2000 to August 2001 at Gujarat Cancer and Research Institute, Ahmedabad. Only those patients who were found unsuitable for conventional brachytherapy or in whom intracavitary radiotherapy was found to be unlikely to encompass the tumor volume were treated with interstitial template brachytherapy using MUPIT applicator and were enrolled for this study. Criteria for inclusion in this study were as follows: Hemoglobin--minimum 10 gm%; Performance Status--70% or more (Karnofsky Scale); Histopathological confirmation; FIGO Stage--IIb-IIIb (excluding frozen pelvis). RESULTS: Among the 30 patients studied, 4 lost to follow-up and they were excluded from the study. With a median follow up of 9 months, local control was achieved in (20/26) 76.92% patients. The local control was better for nonbulky tumors compared to bulky tumors irrespective of stage of disease. Local control rate was better in patients with good regression of disease after EBRT. The time gap between EBRT and implant also had an impact on the outcome. CONCLUSION: Interstitial template brachytherapy by MUPIT is a good alternative to deliver high-dose radiation in locally advanced gynecological malignancies where conventional brachytherapy application is either not feasible or unlikely to encompass tumor volume adequately. The locoregional control obtained is definitely better than external beam therapy alone and within the accepted range of complications. However, long-term follow-up is needed to comment on late morbidities.     

Prognostic significance of Bax, Bcl-2, and p53 expressions in cervical squamous cell carcinoma treated by radiotherapy

OBJECTIVE: The objective was to determine the prognostic significance of the immunohistochemical expressions of Bax, Bcl-2, and p53 in squamous cell carcinoma of the uterine cervix treated by radiotherapy alone. METHODS: One hundred and seventy-four cases of squamous cell carcinoma of the cervix (stage Ib-IVa) diagnosed between January 1996 and December 1998 were investigated for Bax, Bcl-2, and p53 expressions and were correlated to the patients' survival. RESULTS: The mean age of the patients was 54.1 with a range of 29-82 years. There were 23 cases with stage I (13.2%), 99 stage II (56.9%), 51 stage III (29.3%), and 1 case with stage IV (0.6%). The 5-year disease-free survival (DFS) was 70.50% and overall survival (OS) was 65.95%. Bax, Bcl-2, and p53 expressions were seen in 68.4%, 25.9%, and 77.6% of cases, respectively. In multivariate analysis by Cox's regression, age, stage, Bax, and Bcl-2 expressions appeared to be independent prognostic predictors of DFS. Bax expression was associated with good survival (hazard ratio, 0.47) while Bcl-2 expression was associated with poor survival (HR, 2.51). In addition, a combination of Bcl-2+/Bax+ was significantly associated with poorer DFS compared to Bcl-2-/Bax+ (HR 3.55). However, none of the markers or combinations was associated with OS. CONCLUSIONS: Evaluation of Bax and Bcl-2 expressions and their co-expression provide independent prognostic information for the clinical course of the disease and therefore could be developed as a prognostic indicator for cervical cancer.     

Does pretreatment human papillomavirus (HPV) titers predict radiation response and survival outcomes in cancer cervix?--a pilot study

OBJECTIVE: To evaluate if pretreatment HPV titers in cancer cervix could predict radiation response and survival outcomes. METHODS: Twenty-one patients of cancer cervix were treated by radiotherapy (RT) alone. HPV titers were estimated using DNA Hybrid Capture II test. Loco-regional response at 1 month of RT--complete or partial response (CR and PR respectively) and survival outcomes--local disease-free (LDFS), disease-free (DFS) and overall (OS) survivals were evaluated against pre- and posttreatment HPV titers. RESULTS: Pretreatment HPV titers ranged from 0.81 to 3966.10 RLU/cut off (mean +/- SD: 1264.39 +/- 1148.22, median: 1129.98). Of the demographic features evaluated, mean HPV titers were significantly different only for patients achieving CR or PR at completion of RT (mean +/- SD for CR vs. PR: 1616.31 +/- 1146.86 vs. 384.57 +/- 538.80, P = 0.022). HPV titers at end of RT ranged from 0.12 to 487.42 RLU/cut off (mean +/- SD: 37.31 +/- 108.60, median: 2.33). Patients with higher pretreatment HPV titers (>1000 RLU/cutoff) had a higher CR (P = 0.022) and better survival compared to those with < or =1000 RLU/cutoff (LDFS, P = 0.004; DFS, P = 0.005; OS, P = 0.012). At completion of RT, those having > or =99.5% fall in HPV had superior survival outcomes than those with <99.5% reduction (LDFS, P = 0.002; DFS, P = 0.002; OS, P = 0.004). CONCLUSIONS: Higher pretreatment HPV titers (>1000 RLU/cutoff) could be considered as a predictor of radiotherapy response and survival in cancer cervix. A reduction in these titers to 99.5% of their baseline values at end of radiotherapy is also associated with better survival outcomes.     

单纯放疗与以顺铂为主的同步放化疗治疗子宫颈癌的临床效果对比分析

目的对比分析单纯放疗及应用以顺铂为主的同步放化疗治疗宫颈癌初治患者的疗效和并发症。方法选择2000-2006年北京妇产医院收治的初治宫颈癌患者共197例,临床分期为Ⅰb-Ⅳa期,按治疗方法不同分为单纯放疗组（共100例,给予^60Co盆腔外照射及^192Ir腔内后装照射）和同步放化疗组（共97例,给予以顺铂为主的化疗,同步给予放疗,放疗方案与单纯放疗组相同）,对两组患者的疗效及并发症发生情况进行对比分析。结果单纯放疗组与同步放化疗组有效率分别为92％和89％,两组比较,差异无统计学意义（P=0．500）;其5年生存率分别为82％和79％,两组比较,差异无统计学意义（P=0．177）。单纯放疗组和同步放化疗组中Ⅲ期以上、病理分级G3、鳞癌患者的5年生存率分别为56％和84％,两组比较,差异有统计学意义（P〈0．01）;同步放化疗组和单纯组的近期并发症均以骨髓抑制为主,其中Ⅲ度以上骨髓抑制的发生率分别为14％和3％,两组比较,差异有统计学意义（P〈0．01）;其远期并发症的发生率分别为11％和8％,两组比较,差异无统计学意义（P=0．496）。结论应用以顺铂为主的同步放化疗治疗Ⅲ期以上、病理分级G3、鳞癌患者可明显提高其5年生存率。     

Radiotherapy in the adjuvant setting of cervical carcinoma: treatment, results, and prognostic factors

To evaluate the efficacy of postoperative radiotherapy and to investigate prognostic factors for early-stage cervical cancer patients. From December 1993 to December 2001, 141 patients with stage I-II cervical cancer without para-aortic lymph node (LN) metastases and treated by surgery and postoperative radiotherapy (RT) were included in this study. Indications for postoperative external RT were based on pathologic findings, including LN metastasis, positive surgical margins, parametrial involvement, pT2 tumor, and presence of any two minor risk factors like lymphvascular space involvement, deep stromal invasion, and tumor diameter between 2-4 cm. Sixty-six (47%) patients received RT alone, whereas 59 (42%) were treated with RT and concomitant chemotherapy (CT), and 16 received neoadjuvant CT. Patients with positive vaginal margins also received 27.5 Gy high-dose rate vaginal cuff brachytherapy in five fractions. Median follow-up time was 55 months. The actuarial 5-year overall (OS), disease-free (DFS), locoregional recurrence-free (LRFS), and distant metastases-free (DMFS) survival rates are 70%, 68%, 77%, and 88%, respectively. Univariate and multivariate analyses revealed that level and number of metastatic LNs and concomitant CT were unique significant prognostic factors for OS, DFS, and LRFS. Endometrial involvement, on the other hand, was proven to be significant for DFS and DMFS. Patients with less than three LN metastases or having only obturator LN involvement showed similar prognosis with their counterparts having no LN metastases. On the other hand, patients with either common iliac LN or more than three LN metastases had significantly worse outcome. Our results indicate that level and number of metastatic LNs are the most important prognostic factors determining the survival rates, and patients with upper lymphatic involvement or more than three metastatic LNs seem to need more effective treatment approaches.     

Randomized study of preoperative radiation and surgery or irradiation alone in the treatment of stage IB and IIA carcinoma of the uterine cervix: final report

A prospective randomized study in selected patients with Stage IB and IIA carcinoma of the uterine cervix was carried out at Washington University between January 1966 and December 1979. Patients were randomized to be treated with irradiation alone consisting of 1000 cGy whole pelvis, additional 4000 cGy to the parametria with a step wedge midline block, and two intracavitary insertions for 7500 mgh; or irradiation and surgery, consisting of 2000 cGy whole pelvis irradiation, one intracavitary insertion for 5000-6000 mgh followed 2 to 6 weeks later by a radical hysterectomy with pelvic lymphadenectomy. A total of 40 patients with Stage IB and 16 with Stage IIA were randomized to be treated with irradiation alone. A similar group of 48 patients with Stage IB and 14 with IIA were randomized to the preoperative radiation and surgery group. The 5-year, tumor-free actuarial survival for Stage IB patients treated with radiation was 89% and with preoperative radiation and surgery 80%. In Stage IIA, the tumor-free actuarial 5-year survival was 56% for the irradiation alone group and 79% for the patients treated with preoperative radiation and radical hysterectomy. In the patients with Stage IB treated by irradiation alone only one pelvic failure combined with distant metastasis occurred, and 3 patients developed distant metastasis. In the 48 patients treated with combined therapy, there were six pelvic failures (12.5%) all combined with distant metastases and two distant metastases alone. In the 16 patients with Stage IIA treated with radiotherapy alone, there were four pelvic failures (all parametrial), three of them combined with distant metastasis. In the 14 patients treated with irradiation and surgery, two developed a pelvic recurrence, and one distant metastasis. In the preoperative radiation group, the incidence of metastatic pelvic lymph nodes was 6.3% in Stage IB and 7.1% in Stage IIA. Major complications of therapy in the patients treated with radiation alone (10%) consisted of one rectovaginal fistula, two vesicovaginal fistulas, and one rectal stricture. In the preoperative radiation group, three ureteral strictures and two severe proctitis-rectal strictures were noted (8%). The present study shows no significant difference in therapeutic results or morbidity for invasive carcinoma of the uterine cervix Stage IB or IIA treated with irradiation alone or combined with a radical hysterectomy and lymphadenectomy.     

Adjuvant radiotherapy in women with stage I endometrial cancer: a systematic review

OBJECTIVE: To review the literature regarding the role of adjuvant radiotherapy (RT) in women with stage I endometrial cancer in terms of survival and pelvic control. METHODS: A systematic search of MEDLINE, EMBASE and the Cochrane Library databases was conducted for studies evaluating RT (1966 to October 2005). RESULTS: Five randomized trials were identified that evaluated adjuvant external beam radiotherapy (EBRT) and/or intracavitary radiotherapy (ICRT) including one in which women had undergone complete surgical staging. No survival differences were identified; however, none of the studies were powered enough to show a survival benefit. In three studies reporting subgroup analyses, intermediate-risk subgroups (stages IA and IB, grade 3 or stage IC) who received RT had fewer pelvic recurrences compared to women not receiving RT. Unfortunately, none of the studies reported ultimate pelvic control as an outcome. CONCLUSIONS: RT is not recommended in low-risk patients (stages IA, IB, grades 1 and 2). It is reasonable to consider EBRT for intermediate-risk subgroup patients (stage IC, grades 1 and 2, or stages IA, IB, grade 3), regardless of surgical staging, to reduce the risk of pelvic recurrence. EBRT is recommended for high-risk patients (stage IC, grade 3). The benefits of EBRT need to be weighed against the toxicity of treatment. Patients should be informed of the benefits and risks of EBRT. Additional analysis including ultimate pelvic control in subgroups would be helpful. More clinical trials are warranted to further define the role of EBRT in subgroups of patients and to clarify the role of ICRT.     

Complications of combined surgery and radiation therapy for carcinoma of the endometrium

Long-term gastrointestinal (GI) and urinary tract (UT) complications were evaluated in 133 women with carcinoma of the endometrium who were treated by both radiotherapy and hysterectomy. Major complications developed in 8% of patients who received external pelvic radiation but in none with intracavitary radiation. GI complications were more frequent and more severe in patients receiving external pelvic radiation than in those who received only intracavitary radiotherapy, irrespective of the sequence of treatment. UT complications were more frequent with prehysterectomy external radiotherapy (N = 39) than with posthysterectomy external radiotherapy (N = 21).     

Postoperative vaginal brachytherapy alone is the treatment of choice for grade 1–2, stage IC endometrial cancer

The aim was to determine outcome and toxicity in grade 1-2, FIGO stage IC endometrial cancer patients treated with external beam radiotherapy plus vaginal cuff brachytherapy or vaginal cuff brachytherapy alone. Between 1986 and 1999, a total of 132 patients were diagnosed with FIGO stage IC endometrial carcinoma. The median age was 67.5 years (range, 36-88). Median follow-up was 54 months (range, 6-157). Grade 1 disease was present in 64 patients, grade 2 in 45 patients, and grade 3 in 23 patients. Patients with grade 3 disease usually received external radiotherapy and were excluded from this analysis. Of the patients with grade 1-2 disease, 31 received brachytherapy alone and 78 received both external radiotherapy and brachytherapy. Ten (8%) patients experienced failure. Isolated pelvic relapse occurred in five patients. Three patients experienced both distant and local relapse. Two patients had isolated distant relapse. Nine failures occurred in patients treated with both external radiotherapy and brachytherapy. Only one failure occurred in those treated with brachytherapy alone. Overall survival and disease-free survival at 5 years were 85% and 92%, respectively. For those treated with both external radiotherapy and brachytherapy, 5-year locoregional control was 95%. For those treated with brachytherapy alone, 5-year locoregional control was 96.4%. There was no significant survival or local control difference between the two groups. Nine patients (9%) treated with both external radiotherapy and brachytherapy developed Radiation Therapy Oncology Group grade 3-4 toxicity. No patient treated with vaginal cuff brachytherapy alone developed grade 3-4 toxicity (P < 0.001). In patients with well-differentiated (grade 1-2) stage IC endometrial cancer, external beam radiotherapy plus brachytherapy versus vaginal cuff brachytherapy alone achieved equivalent local control and survival. However, vaginal cuff brachytherapy alone produced significantly less toxicity.     

Outcome of 6 fractions of 5.3 Gray HDR brachytherapy in combination with external beam radiotherapy for treatment of cervical cancer

Objective

To review the characteristics, outcomes and toxicities of cervical cancer patients treated with 6 fractions of brachytherapy after external beam radiotherapy (EBRT).

Methods

All patients diagnosed with cervical cancer from 2000 to 2009 who were referred for radical treatment and who received 6 fractions of brachytherapy were retrospectively reviewed. Overall survival (OS), disease free survival (DFS), local control (LC), distant control (DC) rate, acute and late toxicities were the primary endpoints.

Results

Thirty-two patients with mainly advanced stage squamous cell carcinoma were identified and reviewed. Patients received EBRT of 45 to 50.4 Gy in 1.8 Gy daily fractions followed by 6 sessions of 3 channel brachytherapy of 5.3 Gy prescribed to point H. Response rates to treatment were good, with no residual disease in 84% six weeks after the completion of treatment. With a median follow up time of 8.1 years, the five-year OS, DFS, LC and distant control rates were 75%, 68.5%, 92.8% and 76.9% respectively. None of the patients developed any G3-4 acute toxicity but one patient who had advanced disease developed G3-4 proctitis with a fistula formation.

Conclusions

HDR brachytherapy utilizing 6 fractions of 5.3 Gy prescribed to point H with concurrent chemo-radiation is superior in terms of OS and LC to regimens that deliver a lower EQD2 dose to point A/H and is associated with very low rates of toxicities.     

Stereotactic body radiotherapy for pelvic boost in gynecological cancer patients with local recurrence or unsuitable for intracavitary brachytherapy

ObjectiveTo evaluate efficacy of stereotactic body radiotherapy (SBRT) for pelvic boost irradiation in gynecological cancer patients with pelvic recurrence or with intact uterus unsuitable for brachytherapy.Materials and methodsWe retrospectively reviewed the medical records of 25 gynecological cancer patients who received SBRT boost for pelvic recurrence (salvage group, n = 14), or for local dose escalation instead of intracavitary brachytherapy due to unfavorable medical condition (definitive group, n = 11). The pelvis was irradiated with a median dose of 54 Gy in six weeks, and then SBRT was prescribed with a range of 10–25Gy in two to five fractions. The cumulative radiobiological equivalent dose in 2-Gy fractions (EQD2) to the tumors ranged from 62.5 to 89.5 Gy₁₀ (median, 80.7). Overall survival (OS) and in-field relapse-free survival (IFRFS) were calculated using the Kaplan–Meier method.ResultsAt the initial assessment, eighteen (72%) patients achieved complete or partial remission, and seven (28%) had stable or progressive disease. With a median follow duration of 12 months, the 1-year IFRFS for salvage and definitive group were 64.5% and 90.0%, whereas the 1-year OS for the two groups were 80.8% and 49.1%, respectively. One patient developed entero-vaginal fistula and one had sigmoid perforation. No patient experienced ≧ grade 3 genitourinary complications.ConclusionIn gynecological cancer patients with recurrent pelvic tumors or intact uterus unsuitable for brachytherapy, local dose escalation with SBRT resulted in an initial response rate of 72% with acceptable early toxicities. A long-term follow-up is required to assess the impact on local control or survival.