Clinical Investigation
Computed Tomography–Planned High-Dose-Rate Brachytherapy for Treating Uterine Cervical Cancer

https://doi.org/10.1016/j.ijrobp.2016.04.025Get rights and content

Purpose

To evaluate the long-term results of computed tomography (CT)–planned high-dose-rate (HDR) brachytherapy (BT) for treating cervical cancer patients.

Methods and Materials

CT-planned HDR BT was performed according to the adapted Group European de Curietherapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) recommendations in 216 consecutive patients with locally advanced cervical cancer, International Federation of Gynecology and Obstetrics (FIGO) stage IB to IVA, who were treated with conformal external beam radiation therapy and concomitant chemotherapy. We analyzed outcomes and late side effects evaluated according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer and Subjective, Objective, Management, Analysis evaluation scoring system and compared them with the results from a historical group.

Results

The median age was 56 years (range, 32-83 years). The median follow-up time for living patients was 52 months (range 37-63 months). The 5-year cumulative incidence function for the local recurrence rate for patients with FIGO II and III was 5.5% and 20%, respectively (P=.001). The 5-year rates of overall survival (OS) and disease-free survival (DFS) were 66.4% and 58.5%, respectively. The relative risk of failure for OS and DFS for FIGO III in relation to FIGO II was 2.24 (P=.003) and 2.6 (P=.000) and for lymph node enlargement was 2.3 (P=.002) and 2 (P=.006), respectively. In 2 patients, rectovaginal fistula occurred, and in 1 patient, vesicovaginal fistula occurred without local progression. Comparison of late adverse effects in patients treated according to the GEC-ESTRO recommendations and in the historical group revealed a reduction in fistula formation of 59% and also a reduction in rectal grade 3 to 4 late toxicity of >59%.

Conclusions

This is the largest report with mature data of CT-planned BT HDR for the treatment of cervical cancer with good local control and acceptable toxicity. In comparison with the historical series, there is a substantial benefit in terms of severe late effects. FIGO III and enlarged lymph nodes in positron emission tomography–CT/CT are negative prognostic factors, both with a relative risk of failure of approximately 2.

Introduction

Patients with locally advanced cervical cancer require treatment with external beam radiation (EBRT) with concomitant cisplatin-based chemotherapy and subsequent brachytherapy (BT). Although magnetic resonance imaging (MRI) image-guided adaptive BT for cervical cancer is a gold standard, some institutions do not have access to an MRI unit, their unit is located at a significant distance from the clinic, or patients have contraindications for this method (eg, pacemaker, metal prosthesis). The Group European de Curietherapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) has provided recommendations for target delineation using MRI-contoured tumor volumes and organs at risk (OAR) 1, 2. These recommendations were adapted to computed tomography (CT) BT planning 3, 4. To evaluate the long-term results of CT-planned high-dose-rate (HDR) BT for the treatment of cervical cancer patients, a retrospective analysis of the material from the Warsaw Brachytherapy Department was performed. The results were compared with the results obtained from a historical group (5).

Section snippets

Methods and Materials

In 2010 to 2011, 216 consecutive patients with locally advanced cervical cancer International Federation of Gynecology and Obstetrics (FIGO) stage IB-IVA were treated with curative intent after the patients signed written consent. The protocols, consent procedure, and study were approved by the local medical authority. The eligibility criteria included patients after definitive radiation therapy and without a previous history of malignancy. Twelve patients were ineligible for the analysis, 1

Results

The median age was 56 years (range, 32-83 years). The median follow-up time for all patients was 47 months (range, 4-63 months) and for living patients was 52 months (range, 37-63 months).

The 5-year CIF (95% confidence interval [CI]) for local recurrence rate was 10.4% (9.5%-11.2%) (Fig. 1). The 5-year CIF (95% CI) for local recurrence rate for patients with FIGO II and FIGO III was 5.5% (1.5%-9.6%) and 20% (10%-30%), respectively (P=.001).

In the patients with local recurrence, the analysis of

Discussion

Computed tomography is the most commonly performed imaging modality for 3D planning of BT. Unfortunately, published reports concerning CT-based contouring in BT of cervical cancer and the outcomes of such treatment are scarce. CT, unlike MRI, does not clearly differentiate tumor tissue from normal adjacent structures; it is not possible to contour gross tumor volume. Furthermore, it is not possible to exactly define the boundary between the cervix and uterus, and the bowel loops adjacent to the

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Conflict of interest: none.

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