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Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cancer.

ABSTRACT: To evaluate the outcomes of patients with locally advanced cervical cancer treated with three-dimensional image-guided brachytherapy (IGABT) after concomitant chemoradiation (CCRT).Data from patients treated with CCRT followed by magnetic resonance imaging-guided or computed tomography-guided pulsed-dose-rate brachytherapy, performed according to the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology guidelines, were reviewed. At first, stage I or II patients systematically underwent radical hysterectomy or were offered a randomized study evaluating hysterectomy. Then, hysterectomy was limited to salvage treatment.Of 163 patients identified, 27% had stage IB, 57% had stage II, 12% had stage III, and 3% had stage IVA disease. The mean dose delivered (in 2-Gy dose equivalents) to 90% of the high-risk clinical target volume was 78.1 ± 9.6 Gy, whereas the doses delivered to organs at risk were maintained under the usual thresholds. Sixty-one patients underwent a hysterectomy. Macroscopic residual disease was found in 13 cases. With a median follow-up of 36 months (range, 5-79 months), 45 patients had relapsed. The 3-year overall survival rate was 76%. Local and pelvic control rates were 92% and 86%, respectively. According to the Common Toxicity Criteria 3.0, 7.4% of patients experienced late grade 3 or 4 toxicity. Most of those had undergone postradiation radical surgery (2.9% vs. 14.8; p = .005).IGABT combined with CCRT provides excellent locoregional control rates with low treatment-related morbidity, justifying the elimination of hysterectomy in the absence of obvious residual disease. Distant metastasis remains an important first relapse and may warrant more aggressive systemic treatment.

SUBMITTER: Mazeron R

PROVIDER: S-EPMC3639528 | biostudies-other | 2013

REPOSITORIES: biostudies-other

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Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cancer.

Mazeron Renaud R Gilmore Jennifer J Dumas Isabelle I Champoudry Jérôme J Goulart Jennifer J Vanneste Ben B Tailleur Anne A Morice Philippe P Haie-Meder Christine C

The oncologist 20130408 4

<h4>Purpose</h4>To evaluate the outcomes of patients with locally advanced cervical cancer treated with three-dimensional image-guided brachytherapy (IGABT) after concomitant chemoradiation (CCRT).<h4>Materials and methods</h4>Data from patients treated with CCRT followed by magnetic resonance imaging-guided or computed tomography-guided pulsed-dose-rate brachytherapy, performed according to the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology guidelines, were revi ...[more]

PMID: 23568003

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Project description:OBJECTIVE:To compare the accuracy of different methods for image registration in image-guided adaptive brachytherapy (IGABT) for cervical cancer. METHODS:The last treatment planning CT images (CT1) and the first treatment planning CT images (CT2) were acquired from 15 patients with cervical cancer and registered with different match image qualities (retained/removed catheter source in images) and different match regions [target only (S Group)/ interested organ structure (M Group)/body (L Group)] in Velocity3.2 software. The dice similarity coefficient (DSC) between the clinical target volumes (CTV) of the CT1 and CT2 images (CTVCT1 and CTVCT2, respectively) and between the organs-at-risk (OAR) of the two imaging datasets (OARCT1 and OARCT2, respectively) were used to evaluate the image registration accuracy. RESULTS:The auto-segmentation volume of the catheter source using Velocity software based on the CT threshold was the closest to the actual volume within the CT value range of 1700-1800 HU. In the retained group, the DSC for the OARs of was better than or equal to that of the removed group, and the DSC value of the rectum was significantly improved (P < 0.05). For comparison of different match regions, the high-risk target volume (HRCTV) and the low-risk target volume (IRCTV) had the best precision for registration of the target area, which was significantly greater than that of M group and L group (P < 0.05). The M group had better registration accuracy of the target area and the best accuracy for the OARs. The DSC values of the bladder and rectum were significantly better than those of the other two groups (P < 0.05). CONCLUSIONS:The CT value range of 1700-1800 HU is optimal for automatic image segmentation using Velocity software. Automatic segmentation and shielding the volume of the catheter source can improve the image quality. We recommend the use of interested organ structures regions for image registration in image-guided adaptive brachytherapy for cervical cancer.

Project description:This study is to compare the survival outcomes of laparoscopic radical hysterectomy (LRH) to those of abdominal radical hysterectomy (ARH) for patients with locally advanced cervical cancer (LACC). Patients with the International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB2 to IIB LACC who underwent radical hysterectomy between 2001 and 2015 were identified. The disease-free survival (DFS) and overall survival (OS) were compared according to the surgical approach and were adjusted based on clinicopathologic characteristics. A total of 396 patients were included in the study, with 179 (45.2%) and 217 (54.8%) patients in the ARH and LRH groups, respectively. The LRH group showed a significantly lower amount of estimated blood loss, lower blood transfusion rate and shorter length of hospital stay. Overall, there were no significant differences in the 5-year DFS and 5-year OS between the LRH and ARH groups with the Kaplan-Meier method. However, multivariate analyses identified LRH as an independent prognostic factor for a poor DFS (hazard ratio [HR] 2.5; 95% confidence interval [95% CI] 0.19 to 0.87; p = 0.02). The analysis of stage IB2 disease and the squamous subtype (61.9% and 87.9% of all participants, respectively) reached the same conclusion. When stratifying by FIGO stage, the patients with IB2 (n = 348) in the ARH group had a significantly better DFS (HR 0.14, 95% CI 0.05-0.42, p < 0.01) and OS (HR 0.17, 95% CI 0.04-0.67, p = 0.11) than those in the LRH group in the Cox regression model. However, no differences were found in patient with stage IIA1, IIA2, or IIB in Cox regression model. When stratifying by histological types, for the patients with squamous carcinomas (n = 375), in Cox model, ARH had a significantly superior DFS compared with those who underwent LRH (HR 0.45, 95% CI 0.25-0.82, p = 0.01), but the OS was not statistically significant (HR 0.57, 95% CI 0.27-1.20, p = 0.14). However, no differences were found in patient with adenocarcinoma and adenosquamous carcinomas in the Cox model. Therefore, ARH was associated with a higher DFS than LRH in patients with LACC, especially in patients with stage IB2 disease or the squamous subtype.

Project description:PurposeThe ICRU/GEC-ESTRO released the ICRU Report No. 89, which introduced the concept of four-dimensional brachytherapy and ushered in a new era of brachytherapy for cervical cancer. The purpose of this study was to evaluate the local control and late toxicity of four-dimensional brachytherapy in cervical cancer through a systematic review and to reveal the dose-response relationship between the volumetric dose paraments and the local control rate via a probit model.Material and methodsWe identified studies that reported the HR-CTV D90 and local control probabilities by searching the PubMed Database, the Web of Science Core Collection and the Cochrane Library Database through February 1st, 2022. Regression analyses were performed between the HR-CTV D90 and the local control probability using a probit model.ResultsNineteen studies enrolling 3,616 patients were included. The probit model showed a significant relationship between the HR-CTV D90 value and IR-CTV D90 Vs. the local control probability, P < 0.001 and P = 0.003, respectively. The D90 for HR-CTV and IR-CTV corresponding to a probability of 90% local control was 79.1 GyEQD2,10 (95% CI:69.8 - 83.7 GyEQD2,10) and 66.5 GyEQD2,10 (95% CI: 62.8 - 67.9 GyEQD2,10), respectively. The limits for the prescribed dose of 85 GyEQD2,10 for HR-CTV D90 theoretically warranted a 92.1% (95% CI: 90.2% - 95.3%) local control rate, and 87.2% (95% CI: 82.4% - 91.8%) local control probability was expected for 65 GyEQD2,10 to IR-CTV D90. The probit model showed no significant relationship between the D2cc to organs at risk and the probability of grade 3 and above gastrointestinal or genitourinary toxicity.ConclusionsFour-dimensional brachytherapy takes into account uncertain factors such as tumour regression, internal organ motion and organ filling, and provides a more accurate and more therapeutic ratio delivery through adaptive delineation and replanning, replacement of the applicator, and the addition of interstitial needles. The dose volume effect relationship of four-dimensional brachytherapy between the HR-CTV D90 and the local control rate provides an objective planning aim dose.

Project description:BackgroundTo assess the intra-fractional dosimetric variations of image-guided brachytherapy of cervical cancer.MethodsA total of 38 fractions (9 patients) undergoing brachytherapy for cervical cancer underwent a CT scanning for treatment planning (planning CT) and a Cone-beam CT (CBCT) scanning immediately prior to delivery (pre-delivery CBCT). The variations of volumes as well as the dosimetric impact from treatment planning to delivery (intra-application) were evaluated. The dose volume histogram parameters including volume, D90 of high-risk clinical target volume (HRCTV) and D2cc of organs at risk (OARs) were recorded.ResultsThe relative differences (mean ± 1SD) of the volume and D90 HRCTV across the two scans were - 2.0 ± 3.3% and - 1.2 ± 4.5%, respectively. The variations of D2cc for bladder, rectum, sigmoid and small intestine are - 0.6 ± 17.1%, 9.3 ± 14.6%, 7.2% ± 20.5% and 1.5 ± 12.6%, respectively. Most of them are statistically nonsignificant except the D2cc for rectum, which showed a significant increase (P = 0.001). Using 5% and 10% uncertainty of physical dose for HRCTV at a 6 Gy × 5 high-dose-rate schedule, the possibility of total equivalent doses in 2 Gy fractions (EQD2) lower than 85 Gy is close to 0% and 3%, respectively. Performing similar simulation at 15% and 20% uncertainty of a 4 Gy physical dose for OARs, the possibility of total EQD2 dose exceeding 75 Gy is about 70%. Less than 1% of the total EQD2 of OARs would exceed 80 Gy.ConclusionsAverage intra-fractional dosimetric variation of HRCTV was small in an interval of less than 1 h, and the possibility of total EQD2 exceeding 85 Gy is higher than 97%. The intra-fractional dosimetric variations of OARs might result in an overdose for OARs in a single fraction or the whole treatment. It is necessary to detect unfavorable anatomical changes by re-imaging and take interventions to minimize applied doses and reduce the risk of complications.

Project description:Cervical cancer (CC) continues to be a global burden for women, with higher incidence and mortality rates reported annually. Many countries have witnessed a dramatic reduction in the prevalence of CC due to widely accessed robotic radical hysterectomy (RRH). This network meta-analysis aims to compare intraoperative and postoperative outcomes in way of RRH, laparoscopic radical hysterectomy (LTH) and open radical hysterectomy (ORH) in the treatment of early-stage CC.A comprehensive search of PubMed, Cochrane Library and EMBASE databases was performed from inception to June 2016. Clinical controlled trials (CCTs) of above three hysterectomies in the treatment of early-stage CC were included in this study. Direct and indirect evidence were incorporated for calculating values of weighted mean difference (WMD) or odds ratio (OR), and drawing the surface under the cumulative ranking curve (SUCRA).Seventeen 17 CCTs were ultimately enrolled in this network meta-analysis. The network meta-analysis showed that patients treated by RRH and LRH had lower estimated blood loss compared to patients treated by ORH (WMD = -399.52, 95% CI = -600.64~-204.78; WMD = -277.86, 95%CI = -430.84 ~ -126.07, respectively). Patients treated by RRH and LRH had less hospital stay (days) than those by ORH (WMD = -3.49, 95% CI = -5.79~-1.24; WMD = -3.26, 95% CI = -5.04~-1.44, respectively). Compared with ORH, patients treated with RRH had lower postoperative complications (OR = 0.21, 95%CI = 0.08~0.65). Furthermore, the SUCRA value of three radical hysterectomies showed that patients receiving RRH illustrated better conditions on intraoperative blood loss, operation time, the number of resected lymph nodes, length of hospital stay and intraoperative and postoperative complications, while patients receiving ORH demonstrated relatively poorer conditions.The results of this meta-analysis confirmed that early-stage CC patients treated by RRH were superior to patients treated by LRH and ORH in intraoperative blood loss, length of hospital stay and intraoperative and postoperative complications, and RRH might be regarded as a safe and effective therapeutic procedure for the management of CC.

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Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cancer.

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Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cancer.

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