Combined external pelvic chemoradiotherapy and image-guided adaptive brachytherapy in treatment of advanced cervical carcinoma: experience from a single institution

Abstract

Purpose: External pelvic chemoradiotherapy and image-guided adaptive brachytherapy (IGABT) were studied in advanced cervical carcinomas. Treatment modalities were defined and related to outcomes and side effects. Material and methods: From a single cancer center, 138 patients with advanced cervical cancer were recruited. All patients were treated with external radiotherapy and IGABT. A dosimetric study was performed and related to treatment outcome and side effects. Toxicity of the organs at risk was evaluated by the CTCAE-grading system. Results: The median follow-up was 44 months. More than 60% of the tumors were FIGO stage IIB-IIIB and 82% were squamous cell carcinomas. Largest tumor size (width) was in mean 41 mm and 27% had lymph node spread. The mean total external dose was 51 Gy, and the mean total dose to the high-risk clinical target volume (HRCTV) was 88 Gy. In 130 patients (94%), weekly cisplatin was given in 4-6 cycles. The median number of brachytherapy fractions was four, and in 86 patients, interstitial needles were applied. The primary local control was 97% and 94% after four local recurrences. The overall pelvic control was 89%. The overall recurrence rate was 25% and distant metastases rate was 22%. The overall 5-year survival rate was 65% and cancer-specific survival rate was 69%. Prognostic factors were FIGO stage and total brachytherapy dose (D 90) to HRCTV. Late serious toxicity of the bladder and intestine were rare, occurring in only 3% of patients. Conclusions: The local and pelvic control rates were excellent in this series. The IGABT was an important part of the treatment schedule and could probably not be replaced by increasing the external pelvic dose. Adenocarcinomas seemed to benefit from the addition of interstitial needles. Late serious toxicity was rare.

Efectos secundarios de las terapias oncológicas en pacientes con cáncer de cérvix

“…No obstante, esta evidencia difiere de lo presentado por Moller et al, (8) señalando que la toxicidad intestinal solo está presente en un 13,8% y por Pedraza et al, (36), quienes encontraron trastornos digestivos solo en un 22,6%.…”

“…En términos generales, la OMS reconoce tres categorías de tumores epiteliales del cuello uterino: escamosos, glandulares (adenocarcinoma) y otros tumores epiteliales, incluidos los carcinomas Adenoescamosos, los tumores neuroendocrinos y los carcinomas indiferenciados. Los carcinomas de células escamosas representan alrededor del 70% frente al 80% de los cánceres de cuello uterino, mientras que los adenocarcinomas están entre el 20% y el 25% (7,8). Uno de los principales factores de riesgo para este tipo de cáncer es la infección por el Virus del Papiloma Humano (VPH), adquirido por contacto sexual, a consecuencia de conductas de riesgo como múltiples parejas y relaciones sexuales sin protección, entre otros (9).…”

“…Los más frecuentes son: Naúseas, vómito, hiporexia, caída del cabello, mucositis y fatiga. (8,12,15).…”

Review on Treatment Planning Systems for Cervix Brachytherapy (Interventional Radiotherapy): Some Desirable and Convenient Practical Aspects to Be Implemented from Radiation Oncologist and Medical Physics Perspectives

“…The EMBRACE Collaborative Group published in 2010 and 2011 recommendations III and IV for the reconstruction of the applicators and image in IGABT [ 12 , 13 ]. Throughout these years, the number of publications with conclusive results have increased, both in single-institutional series [ 14 , 15 , 16 , 17 , 18 ], a multicentre retrospective study RetroEMBRACE (retrospective study of patients treated with IGABT based on CT or MRI before the beginning of EMBRACE [ 19 ]), and, recently, the definitive comprehensive data from EMBRACE I [ 20 ], with the consolidation of MRI-based IGABT for the treatment of cervical carcinoma. The recommendations of the GEC ESTRO (I–IV) have been used as a conceptual basis worldwide to introduce the IGABT, now being integrated into the current ICRU 89 [ 21 ].…”

“…The EBRT dose is usually 45–50 Gy in 1.8–2 Gy fractions. Lymph nodes, parametria, or pelvic sidewall boosts up to 55–64 Gy are used, depending on the clinical case and the experience of each individual centre [ 18 , 19 ]. Although HDR-BT schemes of 5.5–6 Gy × 5 fractions are recommended in some guidelines, the “nominal” 28 Gy in 4 fractions scheme is well-established thanks to the EMBRACE trials [ 26 ].…”