Complications of pelvic radiation therapy for gynecologic malignancies in elderly women

The purpose of this study was to determine the frequency and severity of complications following pelvic irradiation in elderly women with gynecologic malignancies. A retrospective analysis was conducted of the 60 women over 65 years of age treated with pelvic radiation therapy for cervical (26), endometrial (31) or proximal vaginal (3) cancer at the UCLA Medical Center between 1978 and 1991. Acute grade 3 to 4 gastrointestinal (GI) complications, using Gynecologic Oncology Group (GOG) criteria occured in three of 60 patients (5%). Chronic complications occured in 28 of 49 patients (57%) followed for longer than 3 months after radiation therapy. The 3-year actuarial rate of chronic GI and/or genitourinary (GU) complications was 63% for any grade and 24% for grades 2,3 or 4. Twelve of the 14 grade 2–4 chronic complications were GI. The 3-year actuarial chronic complication rate was 45% for GI compared to 17% for GU ( P = 0.01). The median time to occurrence for GI and GU chronic complications was 8 and 19 months, respectively. In multivariate analysis, two or more pre-existing medical problems ( P = 0.03) and dose of external beam radiation therapy 45 Gy ( P = 0.07) were associated with the development of a chronic complication. We conclude that moderate to severe intestinal complications are common after pelvic irradiation of elderly women, particularly those with two or more pre-existing medical problems. Pelvic radiation therapy should be used judiciously in elderly women.     

Technique and feasibility of radical para-aortic and pelvic lymphadenectomy for gynecologic malignancies: a prospective study

Abstract. Of 284 patients evaluated for entry into the study between January 1986 and June 1990, systematic para-aortic and pelvic lymphadenectomy was performed in 208 cases (108 cervical cancer, 43 and 57 ovarian and endometrial cancer, respectively). The median number of nodes removed was 58, 49 and 54 for cervical, ovarian and endometrial cancer, respectively. The operating data are divided into 2 groups according to the consecutive number of the cases. The median operating time and the median estimated blood loss of lymphadenectomy was 230 minutes (range 120–270) and 390 ml (range 200–3300) in the first 95 cases. These operating data decreased to 150 minutes (range 100–240) and 250 ml (range 100–2800) in the second 113 cases. No surgery-related deaths occurred. Severe hemor-rages (blood loss exceeding 1000 ml) occurred in 6 patients. The obturator nerve was dissected in 1 patient and in 1 case the left ureter was cut. Formation of lymphoceles occurred in 20.4% of patients. Eighteen patients (8.8%) developed deep venous thrombosis. Nine of these patients experienced pulmonary microembolism. In 3 patients a retroperitoneal abscess was diagnosed. One patient developed a fistula of the most proximal part of the right ureter during the third postoperative week. The resection or coagulation of branches of the genito-femoral and obturator nerves determined mild paresthesis localized at the supero-anterior and internal side of thigh in 11 cases (5.4%). No statistically significant differences were found between the clinical (age, weight and previous chemotherapy) and pathological (type of cancer and lymph node status) parameters considered on one hand and postoperative complications on the other.     

妇科恶性肿瘤术后化疗后淋巴囊肿并发感染及治疗分析

目的:探讨妇科恶性肿瘤术后化疗后淋巴囊肿感染的易感因素、防治方法及预防措施。方法:对67例妇科恶性肿瘤患者术后化疗后淋巴囊肿发生感染及治疗情况进行回顾性分析。结果:中性粒细胞计数(ANC)降低、贫血、年龄>60岁患者淋巴囊肿感染率增高,抗生素联合粒细胞集落刺激因子(G-CSF)治疗使化疗后淋巴囊肿感染患者发热及ANC恢复天数分别缩短为(7.0±1.6)天和(6.0±1.3)天。结论:妇科恶性肿瘤术后患者化疗后ANC降低、贫血、患者年龄>60岁是淋巴囊肿感染感染主要易感因素,抗生素加用G-CSF合理应用,能减少淋巴囊肿感染发生率及严重程度。     

Pelvic bone complications following radiation therapy of gynecologic malignancies: clinical evaluation of radiation-induced pelvic insufficiency fractures

OBJECTIVE: To investigate the incidence, clinical and imaging finding of insufficiency fractures (IF) of the female pelvis following radiation therapy. METHODS: We reviewed the radiation oncology records of 158 patients with gynecologic malignancies who underwent external beam radiation therapy of the whole pelvis between April 1993 and March 2004. All patients underwent computed tomography (CT) scan every 6 months in follow-up after radiation therapy and magnetic resonance imaging (MRI) and radionuclide bone scan were added when the patients complained of a pelvic pain. RESULTS: Eighteen of 158 patients (11.4%) developed IF in the irradiated field with a median interval of 6 months (range 3-51) from the completion of external beam radiation therapy. The cumulative incidence of symptomatic IF at 5 years calculated with Kaplan-Meyer methods was 13%. Median age of the patients who developed IF was 70 years (range 48-88), and all of them were postmenopausal. IF occurred in the sacloiliac joints, upper limb of pubic bone, acetabulum, sacral body and 5th lumbar vertebra. Twelve of 18 patients had multiple lesions and 8 had symmetric longitudinal fracture lines parallel to the sacroiliac joints. Avoidance of weight bearing by bed rest and analgesics provided good pain relief in all patients, although symptoms lasted from 3 to 20 months. CONCLUSIONS: Radiation-induced pelvic IF following radiation therapy for gynecologic malignancies were frequently observed in the postmenopausal patients within 1 year after external beam radiation therapy. Symmetric fractures of the both sacroiliac joints were the characteristic pattern of pelvic IF. Knowledge of characteristic imaging pattern of IF is essential in order to rule out the bone metastasis. Therapy recommendations are conservative with analgesics.     

盆腔器官廓清术在复发宫颈癌治疗中的价值

盆腔器官廓清术（盆廓术）为中央型盆腔复发的宫颈癌患者提供了再次治愈的机会。姑息性盆廓术对部分周围型复发患者也可以起到减轻症状和改善生活质量的作用。满意的手术切缘是影响盆廓术疗效和患者预后的最重要因素。术前需要根据患者的临床表现、妇科检查、影像学检查进行重点评估,并综合患者既往治疗情况、一般机体状态、患者心理、术中探查情况等综合考虑,筛选合适病例,并选择合理的手术方式和入路,才能使复发宫颈癌患者从盆廓术中获益。     

Primary treatment of Bartholin''s gland carcinoma with radiation and chemoradiation: a report on ten consecutive cases

We reviewed our experience with primary radiation therapy for Bartholin's gland carcinoma (BGC) as an alternative to traditional surgical treatment. A retrospective study reviewed records from the Cancer Data Registry and Research Patient Data Registry from 1986 to 2002. Charts of ten women identified with BGC were reviewed for demographic information, presenting symptoms, tumor characteristics, treatment modalities, and complications, as well as for recurrence and survival. The incidence of BGC was 2.13% of all invasive vulvar cancer cases at the Massachusetts General Hospital (MGH). Four patients presented with clinical stage I disease, one with stage II, three with stage III, and two with stage IV. The median age at diagnosis was 63.5 years. There were five squamous cell carcinomas, two adenoid cystic carcinomas, two mucinous adenocarcinomas, and one small-cell carcinoma. After a change in treatment policy in 1986 from primary surgery that had often required postoperative radiation therapy, ten consecutive patients were treated with primary radiotherapy or chemoradiation therapy. Treatment included teletherapy combined with a boost to the primary site, regional nodes and/or interstitial brachytherapy. Short-term complications were mild and well tolerated; one patient developed late radiation-associated pelvic fractures. Four tumors recurred with a mean time to recurrence of 31.2 months. The median follow-up was 87.2 months (45-142). Three- and 5-year survivals were 71.5% and 66%, comparable to outcomes after surgery and postoperative radiation therapy. We conclude that primary radiation or chemoradiation therapy offers an effective alternative to surgery in the treatment of BGC with preservation of genital function and low morbidity.     

A phase I study of concurrent weekly topotecan and cisplatin chemotherapy with whole pelvic radiation therapy in locally advanced cervical cancer: a gynecologic oncology group study

Purpose

To determine the maximum tolerated dose (MTD) and acute dose-limiting toxicities (DLT) of intravenous topotecan administered with weekly cisplatin during pelvic radiation therapy in patients with locally advanced cervical cancer.

Methods

Patients were treated at one of two dose levels receiving intravenous topotecan at 0.5 mg/m² and cisplatin at either 30 or 40 mg/m² given weekly for 6 weeks concurrently with pelvic radiation and intracavitary brachytherapy. The primary endpoint for the escalation study was acute dose-limiting toxicities occurring within 30 days of completing radiation therapy.

Results

Eleven patients were enrolled. Dose-limiting toxicity consisting of Grade 3 nausea and vomiting lasting > 24 h in one patient and grade 3 febrile neutropenia in another patient occurred at the first dose level of weekly topotecan 0.5 mg/m² and cisplatin 40 mg/m². This necessitated de-escalation to weekly cisplatin 30 mg/m² in combination with topotecan 0.5 mg/m² and pelvic radiation. This dose level was tolerable in 6 evaluable patients with only one DLT consisting of grade 4 thrombocytopenia, grade 3 abdominal pain and grade 3 elevated gamma glutamyl transpeptidase (GGT).

Conclusions

In women with locally advanced cervical cancer, intravenous topotecan 0.5 mg/m² and cisplatin 30 mg/m² given weekly for 6 weeks with concurrent pelvic radiation and intracavitary brachytherapy were tolerable. Further expansion of the feasibility cohort of this study was suspended based on the results of a phase 3 trial comparing the efficacy of platinum combinations in advanced and recurrent cervical cancer.     

Adjuvant radiation therapy is not necessary in the management of endometrial carcinoma stage I, low-risk cases

In an attempt to create uniform nationwide guidelines for the management of all stages of endometrial carcinoma, and to limit the use of adjuvant radiation therapy in stage I disease to high-risk patients only, a protocol was developed by the Danish Endometrial Cancer group (DEMCA). From September 1986 through August 1988, 1214 women in Denmark with newly diagnosed carcinoma of the endometrium have been treated according to this protocol. This figure represents all endometrial carcinomas diagnosed in Denmark during this 2-year period. The primary treatment was total abdominal hysterectomy and bilateral salpingo-oophorectomy and no preoperative radiation therapy was delivered. In 1039 cases no macroscopic residual tumor and/or microscopic tumor tissue in the resection margins was found following surgery. Based on surgery and histopathology, these patients were classified as: P-stage I low-risk (grade 1 & 2 and 50% myometrial invasion), P-stage I high-risk (grade 1 & 2 and> 50% myometrial invasion, and grade 3), P-stage II and P-stage III (Group 1). Distribution was as follows: P-I low-risk 641 patients, P-I high-risk 235, P-II 105 and P-III (Group 1) 58 patients. No postoperative radiation therapy was given to P-I low-risk cases. P-I high-risk, P-II, and P-III (Group 1) cases received external radiation therapy. Recurrence rate at 68–92 months follow-up was 45/641 (7%) in P-I low-risk, 36/235 (15%) in P-I high-risk, 30/105 (29%) in P-II, and 27/58 (47%) in P-III (Group 1) cases. Fifteen of 17 vaginal recurrences in P-I low-risk cases were salvaged (mean observation time 61 months).     

A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study

BACKGROUND: Despite their low risk for recurrence, many women with endometrial adenocarcinoma receive postoperative radiation therapy (RT). This study was developed to determine if adjunctive external beam irradiation lowers the risk of recurrence and death in women with endometrial cancer International Federation of Gynaecology and Obstetrics (FIGO) stages IB, IC, and II (occult disease). METHODS: Four hundred forty-eight consenting patients with "intermediate risk" endometrial adenocarcinoma were randomized after surgery to either no additional therapy (NAT) or whole pelvic radiation therapy (RT). They were followed to determine toxicity, date and location of recurrence, and overall survival. A high intermediate risk (HIR) subgroup of patients was defined as those with (1) moderate to poorly differentiated tumor, presence of lymphovascular invasion, and outer third myometrial invasion; (2) age 50 or greater with any two risk factors listed above; or (3) age of at least 70 with any risk factor listed above. All other eligible participants were considered to be in a low intermediate risk (LIR) subgroup. RESULTS: Three hundred ninety-two women met all eligibility requirements (202 NAT, 190 RT). Median follow-up was 69 months. In the entire study population, there were 44 recurrences and 66 deaths (32 disease or treatment-related deaths), and the estimated 2-year cumulative incidence of recurrence (CIR) was 12% in the NAT arm and 3% in the RT arm (relative hazard (RH): 0.42; P=0.007). The treatment difference was particularly evident among the HIR subgroup (2-year CIR in NAT versus RT: 26% versus 6%; RH=0.42). Overall, radiation had a substantial impact on pelvic and vaginal recurrences (18 in NAT and 3 in RT). The estimated 4-year survival was 86% in the NAT arm and 92% for the RT arm, not significantly different (RH: 0.86; P=0.557). CONCLUSIONS: Adjunctive RT in early stage intermediate risk endometrial carcinoma decreases the risk of recurrence, but should be limited to patients whose risk factors fit a high intermediate risk definition.     

Quality of life (QOL) in women treated for gynecologic malignancies with radiation therapy: A literature review of patient - reported outcomes

Objective

To summarize the literature on quality of life for patients treated with definitive radiation for gynecologic cancers, with a specific focus on patient reported outcomes.

Methods

A literature review was performed to summarize studies about patient-reported outcomes and quality of life in women with gynecologic malignancies who were treated with definitive radiation therapy. Summaries are by disease site, including endometrial, cervical and vulvar cancers.

Results

Over 20 different survey instruments have been used to describe patient-reported outcomes for women treated with radiation for gynecologic cancer. Regardless of disease site, all patients describe a degree of compromise in physical and social functioning, as well as sexual dysfunction. Specific symptoms which are most bothersome for patients vary by disease site, such as bowel concerns predominating for endometrial cancer patients, while body image is more concerning for cervical cancer patients.

Conclusions

Several quality of life concerns exist for women treated with radiation therapy for gynecologic malignancies. Significant overlap exists in the QOL issues affecting these patients. Whether to combine or separate surveys by diagnosis, treatment type, age, or time point should be explored further. Assessing patients' psychological, emotional, and physical concerns helps to understand long-term adjustment, enabling incorporation of these domains into future trials that will ultimately improve patient well-being.     

A phase II trial of radiation therapy and weekly cisplatin chemotherapy for the treatment of locally-advanced squamous cell carcinoma of the vulva: a gynecologic oncology group study

Objectives

To determine the efficacy and toxicity of radiation therapy and concurrent weekly cisplatin chemotherapy in achieving a complete clinical and pathologic response when used for the primary treatment of locally-advanced vulvar carcinoma.

Methods

Patients with locally-advanced (T3 or T4 tumors not amenable to surgical resection via radical vulvectomy), previously untreated squamous cell carcinoma of the vulva were treated with radiation (1.8 Gy daily × 32 fractions = 57.6 Gy) plus weekly cisplatin (40 mg/m²) followed by surgical resection of residual tumor (or biopsy to confirm complete clinical response). Management of the groin lymph nodes was standardized and was not a statistical endpoint. Primary endpoints were complete clinical and pathologic response rates of the primary vulvar tumor.

Results

A planned interim analysis indicated sufficient activity to reopen the study to a second stage of accrual. Among 58 evaluable patients, there were 40 (69%) who completed study treatment. Reasons for prematurely discontinuing treatment included: patient refusal (N = 4), toxicity (N = 9), death (N = 2), other (N = 3). There were 37 patients with a complete clinical response (37/58; 64%). Among these women there were 34 who underwent surgical biopsy and 29 (78%) who also had a complete pathological response. Common adverse effects included leukopenia, pain, radiation dermatitis, pain, or metabolic changes.

Conclusions

This combination of radiation therapy plus weekly cisplatin successfully yielded high complete clinical and pathologic response rates with acceptable toxicity.     

Current treatment options in uterine endometrial stromal sarcoma: report of a case and review of the literature

Uterine sarcomas are a rare form of uterine cancer. They occur in women from 40 to 60 years and are generally characterized by poor prognosis, a high rate of local recurrence, and distant metastases. Endometrial stromal sarcoma (ESS) accounts for 0.2% of all gynecological malignancies. Forms of possible treatment include surgery, radiotherapy, chemotherapy, and endocrine treatment. Randomized trials analyzing these treatment options are limited due to the rarity of this disease; therefore, a standard therapy could not be established thus far. To present an overview of the current treatment options of ESS, a search of Medline, Embase, and the Cochrane Library was performed and the results concluded. We report the case of a 32-year-old woman who presented with FIGO stage II ESS. Initial treatment with tamoxifen and local perfusion with cisplatin resulted in disease progression and were discontinued. A novel, therapeutic approach using two cycles of combination chemotherapy with doxorubicin and ifosfamide followed by surgery was applied. Five years after surgery, the patient is still in complete remission. Thus, we conclude that although there is no data from randomized trials available, chemotherapy in advanced or metastatic ESS can provide an opportunity for surgical treatment and can lead to long-term remission.     

Role of surgery and radiation therapy in the management of gestational trophoblastic disease

Although sensitive human chorionic gonadotrophin (hCG) assays and advances in chemotherapy have assumed primary importance in the management of gestational trophoblastic disease (GTD), surgery and radiation therapy remain important in the overall management of patients. Management of molar pregnancies consists of surgical evacuation and subsequent monitoring. Hysterectomy may decrease the risk of post-molar trophoblastic disease. When incorporated into the primary management of malignant GTD, hysterectomy decreases chemotherapy requirements for patients with low-risk disease. Surgical intervention is frequently required to control complications of disease or as therapy to stabilize patients during chemotherapy. Salvage hysterectomy or other extirpative procedures may be integrated into the management of patients with chemorefractory disease. Interventional radiographical techniques are useful adjuncts to control haemorrhage from vaginal or pelvic metastases. Radiation therapy may also be combined with chemotherapy for the management of patients with brain metastases or, rarely, isolated metastases at other sites.     

妇炎舒胶囊联合抗菌药物治疗盆腔炎性疾病的有效性及安全性：一项随机对照临床研究#br#

【Abstract】?Objective?To evaluate the efficacy and safety of Fuyanshu capsule(FC) combined with antimicrobial agents in the treatment of dampness-heat stasis syndrome of pelvic inflammatory disease (PID). Methods?A prospective, multicenter, randomized, double-blind design was adopted. A total of 288 PID patients aged 20 to 50 years were enrolled in 5 hospitals from June 2017 to September 2018, and randomly assigned to study group (treated with Fuyanshu capsule) and control group (treated with placebo) according to a 1:1 ratio. 144 cases in both groups were additively given levofloxacin tablets + metronidazole tablets from the 1st to 14th day of admission. The score of McCormack scale and traditional Chinese medicine (TCM) syndromes were compared between the two groups after 8 weeks of treatment (after 2 menstrual cycles). Follow-up was performed one month after drug withdrawal. Results?The score of McCormack scale in the study group was lower than that before treatment [(7.65±2.21) points] and higher than that in the control group [(4.01±2.46) points] (P<0.0001). The effective rate of TCM syndrome in the study group [93.75% (135/144)] was higher than that in the control group [41.67% (60/144)] (P<0.0001).The recurrence rate of the study group was 3.50% (5/144) and the incidence of pelvic pain was 10.49% (15/144) within one month after drug withdrawal, both of which were lower than those of the control group (P<0.0001). Conclusions?Antibiotics combined with FC improved the score of McCormack scale, curative effect of TCM syndromes, disease recurrence and sequelae of pelvic pain in PID patients better than antibiotics alone.     

The use of Palma''s procedure in the salvage therapy for a leiomyosarcoma of the right pelvic sidewall: an intraoperative multidisciplinary approach

Leiomyosarcomas of the ovary and broad ligament are relatively rare. Less than 50 cases of primary ovarian and broad ligament leiomyosarcomas have been reported. The prognosis is poor, with late-stage disease being a problem in the majority of cases. It is difficult to determine the exact role of surgery, chemotherapy, and radiotherapy in the management of these tumors. So far, no cases of ovarian or broad ligament leiomyosarcomas have been reported where primary surgery for the sarcoma had to be combined with a Palma's procedure. We report a case of a right pelvic sidewall leiomyosarcoma with involvement of 10 cm of the right external iliac vein. A review of the imaging preoperatively did not suggest involvement of the venous system. Resection of the pelvic mass was carried out and a Palma's procedure was performed by the vascular surgeon. Histology reported an incompletely excised high-grade leiomyosarcoma. Chemotherapy was given postoperatively. Imaging at 12 months after surgery showed a patent vascular graft and no evidence of recurrence. There was no clinical evidence of recurrence at 21 months postsurgery.