Salvage interstitial brachytherapy based on computed tomography for recurrent cervical cancer after radical hysterectomy and adjuvant radiation therapy: case presentations and introduction of the technique

Abstract

PurposeLocally recurring cervical cancer after surgery and adjuvant radiotherapy remains a major therapeutic challenge. This paper presents a new therapeutic technique for such patients: interstitial brachytherapy (BT) guided by real-time three-dimensional (3D) computed tomography (CT).Material and methodsSixteen patients with recurrent cervical cancer after radical surgery and adjuvant external-beam radiotherapy (EBRT) were included in this study. These patients underwent high-dose-rate (HDR) interstitial BT with free-hand placement of metal needles guided by real-time 3D-CT. Six Gy in 6 fractions were prescribed for the high-risk clinical target volume (HR-CTV). D90 and D100 for HR-CTV of BT, and the cumulative D2cc for the bladder, rectum, and sigmoid, including previous EBRT and present BT were analyzed. Treatment-related complications and 3-month tumor-response rates were investigated.ResultsThe mean D90 value for HR-CTV was 52.5 ± 3.3 Gy. The cumulative D2cc for the bladder, rectum, and sigmoid were 85.6 ± 5.8, 71.6 ± 6.4, and 69.6 ± 5.9 Gy, respectively. The mean number of needles was 6.1 ± 1.5, with an average depth of 3.5 ± 0.9 cm for each application. Interstitial BT was associated with minor complications and passable tumor-response rate.ConclusionsInterstitial BT guided by real-time 3D-CT for recurrent cervical cancer results in good dose-volume histogram (DVH) parameters. The current technique may be clinically feasible. However, long-term clinical outcomes should be further investigated.

Image-Guided Brachytherapy for Salvage Reirradiation: A Systematic Review

“…Over the past 20 years, 14 retrospectives series, and one phase II prospective study with only few patients [ 31 ], reported clinical experiences of high dose rate (HDR) or low dose rate (LDR) 3D-IGBT in previously irradiated pelvic recurrences of gynecologic malignancies ( Table 1 ) [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. In nine of those, 100% of the population received prior BT, prior EBRT, or a combination of EBRT followed with BT [ 31 , 32 , 33 , 36 , 40 , 41 , 43 , 44 , 45 ]. In the six remaining articles, only a variable subset of patients (from 10% to 85.7% of the studied population) received IGBT in a re-irradiation setting [ 34 , 35 , 37 , 38 , 39 , 42 ].…”

“…The median follow-up was available in 12/14 studies (not reported in two [ 36 , 37 ]) and ranged from 16.3 to 55.6 months (median, 27.6 months).…”

“…The vast majority of the studies focused on isolated local recurrences, occurring in the vagina, paravaginal, pelvic sidewall, cervix (if hysterectomy was not performed as a part of the initial treatment), vulva or sub-urethra [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 45 ]. In only one study, regional and distant metastasis were not excluded, and occurred simultaneously to local relapse in four patients (two patients (9.1%) with nodal involvement and two patients (9.1%) with distant oligometastasis) [ 44 ].…”

“…Regarding primary disease, four studies included cervical cancer exclusively [ 33 , 36 , 40 , 41 ] and three studies included endometrial cancer [ 35 , 39 , 44 ]. In the remaining eight studies, several gynecologic malignancies were mixed up, with a majority of cervical and endometrial primaries and a few vaginal and/or vulvar primitives.…”

“…Gold seeds were sometimes used, placed in the superior, inferior, and lateral boundaries of the tumor [ 31 , 34 ]. Liu et al performed interstitial implantation under real time 3D-CT guidance [ 36 ]. Interstitial BT was performed using a perineal template (Syed-Neblett template, Martinez Universal Perineal Interstitial Template (MUPIT), or institutional templates) or with free-hand needle application with a vaginal applicator.…”