Determination of Prognostic Factors for Vaginal Mucosal Toxicity Associated With Intravaginal High-Dose Rate Brachytherapy in Patients With Endometrial Cancer

Bahng, Agnes Y.; Dagan, Avner; Bruner, Deborah Watkins; Lin, Lilie L.

doi:10.1016/j.ijrobp.2010.10.071

Cited by 77 publications

(69 citation statements)

References 31 publications

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“…Other factors including age and menopausal status were also found to be significant for developing vaginal mucositis in patients treated with ERT and vaginal BRT. 14,16 Thus, such factors may be important to consider because the vaginal mucosa of older, post-menopausal females becomes thin, is replaced by connective tissue and loses its vasculature, so the vaginal cylinder could not contact the whole vaginal mucosa, when compared with the vaginal mucosa of younger, pre-menopausal females, as observed in our study.…”

Section: Discussionmentioning

confidence: 60%

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The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

Onal

Güler²,

Dolek³

2015

BJR

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Objective: To evaluate the incidence, size and predisposing factors for air pockets around the vaginal cylinder and their dosimetric effect on the vaginal mucosa. Methods: We investigated 174 patients with endometrial carcinoma treated with external radiotherapy (RT) and brachytherapy (BRT) (101 patients, 58%) or BRT alone (73 patients, 42%). The quantity, volume and dosimetric impact of the air pockets surrounding the vaginal cylinder were quantified. The proportions of patients with or without air pockets during application were stratified according to menopausal status, treatment modality and interval between surgery and RT. Results: Air pockets around the vaginal cylinder were seen in 75 patients (43%), while 99 patients (57%) had no air pockets. Only 11 patients (6.3%) received less than the prescribed dose (average 93.9% of prescribed dose; range, 79.0-99.2%). Air pockets were significantly fewer in pre-menopausal patients or in patients treated with the combination of external RT and BRT than in postmenopausal patients or patients treated with BRT alone. A significant correlation existed between the mucosal displacement of the air gap and the ratio of the measured dose at the surface of the air gap and prescribed dose (Pearson r 5 20.775; p , 0.001). Conclusion: Air pockets were still a frequent problem during vaginal vault BRT, especially in post-menopausal patients or in patients treated with BRT alone, which may potentially cause dose reductions at the vaginal mucosa. Advances in knowledge: Air pockets around the vaginal cylinder remain a significant problem, which may potentially cause dose reduction in the target volume.The primary treatment of choice in localized endometrial cancer is surgery. Adjuvant radiotherapy (RT) is recommended in intermediate-and high-risk patients in order to diminish disease recurrence. RT can be in the form of external RT (ERT) with vaginal vault brachytherapy (BRT) or BRT only, depending on the risk factors and stage of disease.The purpose of vaginal vault BRT is to eradicate a microscopic tumour at the lymphatics located in the vaginal vault. It was demonstrated that .90% of lymphatics lie within 2-3 mm from the surface of stretched mucosa.1 For this reason, in order to deliver adequate doses to the submucosal lymphatics, the vaginal cylinder must be in direct contact with the vaginal surface, as recommended by the American Brachytherapy Society (ABS).2 The Group Europeén de Curiethérapie and the European Society for Radiotherapy & Oncology (GEC-ESTRO) guidance 3 is to prescribe vaginal BRT to 5 mm from the applicator surface with a 2-mm tolerance. The most commonly used applicator for vaginal vault high-dose-rate BRT is a segmented cylinder. 4 However, during application, air gaps may be observed, which may potentially cause underdosage of the vaginal mucosa.Cameron et al 5 found that 18 of 25 patients (72%) had air gaps .2 mm in the cranial part of the vagina, with the median number of air pockets per patient being 1 (range, 0-5). Richardson et al 6 reported that 20 o...

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Section: Discussionmentioning

confidence: 60%

“…14,15 In patients treated with ERT, vaginal mucosal swelling and mucositis start during treatment because of dilatation of mucosal vessels causing oedema. Therefore, the vaginal cylinder could potentially cover the whole mucosal surface, with less air gaps observed, as seen in our study.…”

Section: Discussionmentioning

confidence: 99%

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

Onal

Güler²,

Dolek³

2015

BJR

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“…The reason why sexual toxicity has been frequently under reported is due to patient reluctance as a result of which these problems are infrequently expressed. Since studies have shown that symptomatic vaginal toxicities can adversely affect the patient's quality of life (Nout et al, 2009), it is important for the clinicians to discuss these issues with the patients and include them in the toxicity grading scale (Bahng et al, 2012).…”

Section: Discussionmentioning

confidence: 99%

Vaginal Dose, Toxicity and Sexual Outcomes in Patients of Cervical Cancer Undergoing Image Based Brachytherapy

Rai

Dhanireddy²,

Patel³

et al. 2014

Asian Pacific Journal of Cancer Prevention

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Background: The aim of the study was to evaluate the vaginal dose and toxicity in patients of cervical cancer treated with image guided brachytherapy at our institute. Materials and Methods: Thirty-five patients treated with image based brachytherapy for cervical cancer were included. Vaginal contouring was done on MRI at brachytherapy and with CT scans of subsequent brachytherapy fractions. Dose volume parameters (DVH) were reported in accordance with the GEC-ESTRO guidelines. These were correlated with vaginal toxicity (assessed by CTCAE version 3) and quality of sexual life assessed at one year of completion of treatment. Results: Vaginal shortness was observed in 22 out of 30 (62.8%) patients, Nine (25.7%) had vaginal dryness and in 10 (28.5%) patients, there was contact bleeding. No association could be demonstrated between the dose volume parameters and vaginal toxicity in the present study. Conclusions: The lack of association between dose volume parameters of vagina with vaginal morbidity may be due to uncertainties involved in the delineation of vaginal wall and dosimetry. Future research is required to accurately define vaginal dose distribution to study its correlation with vaginal morbidity. Vaginal morbidity needs to be documented in order to improve the sexual outcome in these patients.

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“…8.8 Gy at surface beam spatially fractionated grid radiotherapy, 25 although on the other hand it may also risk possible vaginal side effects 3,23 such as vaginal stenosis, since the applicator tip can receive a high dose.…”

Section: Gy At 5 MM Depthmentioning

confidence: 99%

Therapeutic analysis of high-dose-rate ¹⁹² Ir vaginal cuff brachytherapy for endometrial cancer using a cylindrical target volume model and varied cancer cell distributions

et al. 2015

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Purpose: To evaluate high-dose-rate (HDR) vaginal cuff brachytherapy (VCBT) in the treatment of endometrial cancer in a cylindrical target volume with either a varied or a constant cancer cell distributions using the linear quadratic (LQ) model. Methods: A Monte Carlo (MC) technique was used to calculate the 3D dose distribution of HDR VCBT over a variety of cylinder diameters and treatment lengths. A treatment planning system (TPS) was used to make plans for the various cylinder diameters, treatment lengths, and prescriptions using the clinical protocol. The dwell times obtained from the TPS were fed into MC. The LQ model was used to evaluate the therapeutic outcome of two brachytherapy regimens prescribed either at 0.5 cm depth (5.5 Gy × 4 fractions) or at the vaginal mucosal surface (8.8 Gy × 4 fractions) for the treatment of endometrial cancer. An experimentally determined endometrial cancer cell distribution, which showed a varied and resembled a half-Gaussian distribution, was used in radiobiology modeling. The equivalent uniform dose (EUD) to cancer cells was calculated for each treatment scenario. The therapeutic ratio (TR) was defined by comparing VCBT with a uniform dose radiotherapy plan in term of normal cell survival at the same level of cancer cell killing. Calculations of clinical impact were run twice assuming two different types of cancer cell density distributions in the cylindrical target volume: (1) a half-Gaussian or (2) a uniform distribution. Results: EUDs were weakly dependent on cylinder size, treatment length, and the prescription depth, but strongly dependent on the cancer cell distribution. TRs were strongly dependent on the cylinder size, treatment length, types of the cancer cell distributions, and the sensitivity of normal tissue. With a half-Gaussian distribution of cancer cells which populated at the vaginal mucosa the most, the EUDs were between 6.9 Gy × 4 and 7.8 Gy × 4, the TRs were in the range from (5.0) 4 to (13.4) 4 for the radiosensitive normal tissue depending on the cylinder size, treatment lengths, prescription depth, and dose as well. However, for a uniform cancer cell distribution, the EUDs were between 6.3 Gy × 4 and 7.1 Gy × 4, and the TRs were found to be between (1.4) 4 and (1.7) 4 . For the uniformly interspersed cancer and radio-resistant normal cells, the TRs were less than 1. The two VCBT prescription regimens were found to be equivalent in terms of EUDs and TRs. Conclusions: HDR VCBT strongly favors cylindrical target volume with the cancer cell distribution following its dosimetric trend. Assuming a half-Gaussian distribution of cancer cells, the HDR VCBT provides a considerable radiobiological advantage over the external beam radiotherapy (EBRT) in terms of sparing more normal tissues while maintaining the same level of cancer cell killing. But for the uniform cancer cell distribution and radio-resistant normal tissue, the radiobiology outcome of the HDR VCBT does not show an advantage over the EBRT. This study strongly suggests that radiation therapy desi...

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Determination of Prognostic Factors for Vaginal Mucosal Toxicity Associated With Intravaginal High-Dose Rate Brachytherapy in Patients With Endometrial Cancer

Cited by 77 publications

References 31 publications

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

Vaginal Dose, Toxicity and Sexual Outcomes in Patients of Cervical Cancer Undergoing Image Based Brachytherapy

Therapeutic analysis of high-dose-rate ¹⁹² Ir vaginal cuff brachytherapy for endometrial cancer using a cylindrical target volume model and varied cancer cell distributions

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Determination of Prognostic Factors for Vaginal Mucosal Toxicity Associated With Intravaginal High-Dose Rate Brachytherapy in Patients With Endometrial Cancer

Cited by 77 publications

References 31 publications

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

Vaginal Dose, Toxicity and Sexual Outcomes in Patients of Cervical Cancer Undergoing Image Based Brachytherapy

Therapeutic analysis of high-dose-rate 192 Ir vaginal cuff brachytherapy for endometrial cancer using a cylindrical target volume model and varied cancer cell distributions

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Product

Resources

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Therapeutic analysis of high-dose-rate ¹⁹² Ir vaginal cuff brachytherapy for endometrial cancer using a cylindrical target volume model and varied cancer cell distributions