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Outcomes with volume-based dose specification in CT-planned high-dose-rate brachytherapy for stage I-II cervical carcinoma: A 10-year institutional experience

  • Linda P. Cho
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
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  • Matthias Manuel
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
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  • Paul Catalano
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard T.H. Chan School of Public Health, Boston, MA, United States
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  • Larissa Lee
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
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  • Antonio L. Damato
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
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  • Robert A. Cormack
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
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  • Ivan Buzurovic
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
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  • Mandar Bhagwat
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
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  • Desmond O'Farrell
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
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  • Phillip M. Devlin
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
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  • Author Footnotes
    1 Present address: Johns Hopkins Medicine, Department of Radiation Oncology and Molecular Radiation Sciences, 401 North Broadway, Baltimore, MD 21287, United States.
    Akila N. Viswanathan
    Correspondence
    Corresponding author formerly at: Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis Street, ASBI-L2, Boston, MA 02115, United States.
    Footnotes
    1 Present address: Johns Hopkins Medicine, Department of Radiation Oncology and Molecular Radiation Sciences, 401 North Broadway, Baltimore, MD 21287, United States.
    Affiliations
    Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
    Search for articles by this author
  • Author Footnotes
    1 Present address: Johns Hopkins Medicine, Department of Radiation Oncology and Molecular Radiation Sciences, 401 North Broadway, Baltimore, MD 21287, United States.
Published:October 06, 2016DOI:https://doi.org/10.1016/j.ygyno.2016.09.017

      Highlights

      • Large tumor size was associated with an increased risk of any recurrence
      • Overall, there was an overall decrease in point A dose over 5 fractions
      • Point A dose was lower for those without relapse than those with relapse
      • CT-based rather than point A based BT results in outstanding local control

      Abstract

      Objective

      To determine prognostic factors for progression-free survival (PFS) and overall survival (OS) for stage I-II cervical-cancer patients treated using computed-tomography (CT)-planned high-dose-rate (HDR) intracavitary brachytherapy (BT).

      Methods

      A total of 150 patients were treated for Stage I-II cervical cancer using CT-planned BT between 4/2004 and 10/2014. Of these, 128 were eligible for inclusion. Kaplan-Meier local control (LC), pelvic control (PC), overall survival (OS), and PFS estimates were calculated.

      Results

      After a median follow-up of 30 months, the 2-year LC rate was 96%, PFS was 88%, and OS was 88%. Overall, 18 patients (14%) experienced any recurrence (AR), 8 had distant recurrence only and 10 had a combination of local, pelvic, regional, and distant recurrence. No patients had LR only. A prognostic factor for AR was tumor size >4 cm (p = 0.01). Patients with tumors >4 cm were 3.3 times more likely to have AR than those with tumors ≤4 cm (hazard ratio [HR] = 3.3; 95% confidence interval [CI] 1.28–9.47). Point A was 85% of prescription for tumors < 4 cm and decreased approximately 3% over 5 fractions compared to 90% of prescription for tumors > 4 cm that decreased approximately 4% over 5 fractions. Two patients (2%) experienced grade ≥ 2 late toxicity. There were no acute or late grade ≥ 3 toxicities.

      Conclusion

      CT-planned BT resulted in excellent local control and survival. Large tumor size was associated with an increased risk of recurrence outside the radiation field and worse PFS and OS. A volume-optimized plan treated a smaller area than a point A standard plan for patients with Stage I-II cervical cancer that have received chemoradiation. Given the outstanding LC achieved with modern therapy including chemoradiation, HDR, and image-based BT, further efforts to combat spread outside the radiation field with novel therapies are warranted.

      Keywords

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      References

        • Eifel P.J.
        • Winter K.
        • Morris M.
        • Levenback C.
        • Grigsby P.W.
        • Cooper J.
        • et al.
        Pelvic irradiation with concurrent chemotherapy versus pelvic and para-aortic irradiation for high-risk cervical cancer: an update of radiation therapy oncology group trial (RTOG) 90-01.
        J. Clin. Oncol. 2004; 22: 872-880
        • Potter R.
        • Georg P.
        • Dimopoulos J.C.
        • Grimm M.
        • Berger D.
        • Nesvacil N.
        • et al.
        Clinical outcome of protocol based image (MRI) guided adaptive brachytherapy combined with 3D conformal radiotherapy with or without chemotherapy in patients with locally advanced cervical cancer.
        Radiotherapy and Oncology : journal of the European Society for Therapeutic Radiology and Oncology. 2011; 100: 116-123
        • Han K.
        • Viswanathan A.N.
        Brachytherapy in gynecologic cancers: why is it underused?.
        Curr. Oncol. Rep. 2016; 18: 26
        • Viswanathan A.N.
        • Thomadsen B.
        American brachytherapy society cervical cancer recommendations Committee, American brachytherapy society consensus guidelines for locally advanced carcinoma of the cervix. Part I: General Principles.
        Brachytherapy. 2012; 11: 33-46
        • Levitt S.H.
        Technical basis of Radiation Therapy : Practical Clinical Applications.
        5th ed. Springer, Heidelberg; New York2012: 1148
        • Potter R.
        • Haie-Meder C.
        • Van Limbergen E.
        • Barillot I.
        • De Brabandere M.
        • Dimopoulos J.
        • et al.
        Recommendations from gynaecological (GYN) GEC ESTRO working group (II): concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy-3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology.
        Radiother. Oncol.: J. Eur. Soc. Ther. Radiol. Oncol. 2006; 78: 67-77
        • Viswanathan A.N.
        • Dimopoulos J.
        • Kirisits C.
        • Berger D.
        • Potter R.
        Computed tomography versus magnetic resonance imaging-based contouring in cervical cancer brachytherapy: results of a prospective trial and preliminary guidelines for standardized contours.
        Int. J. Radiat. Oncol. Biol. Phys. 2007; 68: 491-498
        • Viswanathan A.N.
        • Erickson B.
        • Gaffney D.K.
        • Beriwal S.
        • Bhatia S.K.
        • Lee Burnett 3rd, O.
        • et al.
        Comparison and consensus guidelines for delineation of clinical target volume for CT- and MR-based brachytherapy in locally advanced cervical cancer.
        Int. J. Radiat. Oncol. Biol. Phys. 2014; 90: 320-328
        • Viswanathan A.N.
        • Cormack R.
        • Holloway C.L.
        • Tanaka C.
        • O'Farrell D.
        • Devlin P.M.
        • et al.
        Magnetic resonance-guided interstitial therapy for vaginal recurrence of endometrial cancer.
        Int. J. Radiat. Oncol. Biol. Phys. 2006; 66: 91-99
        • Tanderup K.
        • Viswanathan A.N.
        • Kirisits C.
        • Frank S.J.
        Magnetic resonance image guided brachytherapy.
        Semin. Radiat. Oncol. 2014; 24: 181-191
        • Grover S.
        • Harkenrider M.M.
        • Cho L.P.
        • Erickson B.
        • Small C.
        • Small Jr., W.
        • et al.
        Image guided cervical brachytherapy: 2014 survey of the American brachytherapy society.
        Int. J. Radiat. Oncol. Biol. Phys. 2016; 94: 598-604
        • Viswanathan A.
        • Hansen J.
        • Cormack R.
        Part IV institutional experiences: practical approaches to image-guided brachytherapy; USA: Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston.
        in: N. A. CK V. Erickson B.E. Pötter R. Gynecologic Radiation Therapy: Novel Approaches to Image-Guidance and Management. Springer, Berlin Heidelberg2011: 225-230
        • Collins Y.
        • Holcomb K.
        • Chapman-Davis E.
        • Khabele D.
        • Farley J.H.
        Gynecologic cancer disparities: a report from the health disparities taskforce of the Society of Gynecologic Oncology.
        Gynecol. Oncol. 2014; 133: 353-361
        • Kaplan E.L.
        • Meier P.
        Nonparametric estimation from incomplete observations.
        J. Am. Stat. Assoc. 1958; 53: 457-481
        • Box J.F.
        Guinness, Gosset, fisher, and small samples.
        Stat. Sci. 1987; 2: 45-52
        • Stigler S.M.
        Gauss and the Invention of Least Squares.
        1981: 465-474
        • Cox D.R.
        Regression models and life-tables.
        J. R. Stat. Soc. Ser. B Methodol. 1972; 34: 187-220
        • Haie-Meder C.
        • Potter R.
        • Van Limbergen E.
        • Briot E.
        • De Brabandere M.
        • Dimopoulos J.
        • et al.
        Recommendations from Gynaecological (GYN) GEC-ESTRO working group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy with emphasis on MRI assessment of GTV and CTV.
        Radiother. Oncol.: J. Eur. Soc. Ther. Radiol. Oncol. 2005; 74: 235-245
        • Dimopoulos J.C.
        • Lang S.
        • Kirisits C.
        • Fidarova E.F.
        • Berger D.
        • Georg P.
        • et al.
        Dose-volume histogram parameters and local tumor control in magnetic resonance image-guided cervical cancer brachytherapy.
        Int. J. Radiat. Oncol. Biol. Phys. 2009; 75: 56-63
        • Kapur T.
        • Egger J.
        • Damato A.
        • Schmidt E.J.
        • Viswanathan A.N.
        3-T MR-guided brachytherapy for gynecologic malignancies.
        Magn. Reson. Imaging. 2012; 30: 1279-1290
        • Fyles A.W.
        • Pintilie M.
        • Kirkbride P.
        • Levin W.
        • Manchul L.A.
        • Rawlings G.A.
        Prognostic factors in patients with cervix cancer treated by radiation therapy: results of a multiple regression analysis.
        Radioth. Oncol.: J. Eur. Soc. Ther. Radiol. Oncol. 1995; 35: 107-117
        • Potter R.
        • Knocke T.H.
        • Fellner C.
        • Baldass M.
        • Reinthaller A.
        • Kucera H.
        Definitive radiotherapy based on HDR brachytherapy with iridium 192 in uterine cervix carcinoma: report on the Vienna University hospital findings (1993-1997) compared to the preceding period in the context of ICRU 38 recommendations.
        Cancer Radiotherapie: Journal de la Societe francaise de radiotherapie oncologique. 2000; 4: 159-172
        • Tan L.T.
        • Coles C.E.
        • Hart C.
        • Tait E.
        Clinical impact of computed tomography-based image-guided brachytherapy for cervix cancer using the tandem-ring applicator - the Addenbrooke's experience.
        Clin. Oncol. 2009; 21: 175-182
        • Tan L.T.
        DWDaCC. Long term outcome of CT-based image-guided brachytherapy for cervix cancer using the Tandem-Ring Applicator.
        OMICS J. Radiol. 2014; (Special Issue 1-003: Image Guided Radiotherapy)
        • Kang H.C.
        • Shin K.H.
        • Park S.Y.
        • Kim J.Y.
        3D CT-based high-dose-rate brachytherapy for cervical cancer: clinical impact on late rectal bleeding and local control.
        Radiother. Oncol.: J. Eur. Soc. Ther. Radiol. Oncol. 2010; 97: 507-513
        • Kato S.
        • Tran D.N.
        • Ohno T.
        • Nakano T.
        • Kiyohara H.
        • Ohkubo Y.
        • et al.
        CT-based 3D dose-volume parameter of the rectum and late rectal complication in patients with cervical cancer treated with high-dose-rate intracavitary brachytherapy.
        J. Radiat. Res. 2010; 51: 215-221
        • Hallock A.
        • Surry K.
        • Batchelar D.
        • Vanderspek L.
        • Yuen J.
        • Hammond A.
        • et al.
        An early report on outcomes from computed tomographic-based high-dose-rate brachytherapy for locally advanced cervix cancer: a single institution experience.
        Prac. Radiat. Oncol. 2011; 1: 173-181
        • Simpson D.R.
        • Scanderbeg D.J.
        • Carmona R.
        • McMurtrie R.M.
        • Einck J.
        • Mell L.K.
        • et al.
        Clinical outcomes of computed tomography-based volumetric brachytherapy planning for cervical cancer.
        Int. J. Radiat. Oncol. Biol. Phys. 2015; 93: 150-157
        • Murakami N.
        • Kasamatsu T.
        • Wakita A.
        • Nakamura S.
        • Okamoto H.
        • Inaba K.
        • et al.
        CT based three dimensional dose-volume evaluations for high-dose rate intracavitary brachytherapy for cervical cancer.
        BMC Cancer. 2014; 14: 447
        • Tanderup K.
        • Nielsen S.K.
        • Nyvang G.B.
        • Pedersen E.M.
        • Rohl L.
        • Aagaard T.
        • et al.
        From point a to the sculpted pear: MR image guidance significantly improves tumour dose and sparing of organs at risk in brachytherapy of cervical cancer.
        Radiother. Oncol.: J. Eur. Soc. Ther. Radiol. Oncol. 2010; 94: 173-180
        • Viswanathan A.N.
        • Erickson B.A.
        Three-dimensional imaging in gynecologic brachytherapy: a survey of the American brachytherapy society.
        Int. J. Radiat. Oncol. Biol. Phys. 2010; 76: 104-109
        • Mazeron R.
        • Gilmore J.
        • Dumas I.
        • Champoudry J.
        • Goulart J.
        • Vanneste B.
        • et al.
        Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cancer.
        Oncologist. 2013; 18: 415-422
        • Charra-Brunaud C.
        • Peiffert D.
        Preliminary results of a French prospective-multicentric study of 3D pulsed dose-rate brachytherapy for cervix carcinoma.
        Cancer radiotherapie: Journal de la Societe francaise de radiotherapie oncologique. 2008; 12: 527-531
        • Eskander R.N.
        • Scanderbeg D.
        • Saenz C.C.
        • Brown M.
        • Yashar C.
        Comparison of computed tomography and magnetic resonance imaging in cervical cancer brachytherapy target and normal tissue contouring.
        Int. J. Gynecol. Cancer: Off. J. Int. Gynecol. Cancer Soc. 2010; 20: 47-53